Medicaid Home and Community-Based Waivers Manual - Appendix A

APPENDIX A: Level of Care

A-1 Long Term Care Functional Screen (PDF, 123 KB)
A-2 Children's Long-Term Care Functional Screen (PDF, 147 KB)
A-3 QMRP Definition (PDF, 6 KB)
A-4 Request for Title XIX Care Level Determination
F-62256 (PDF Fillable, 171 KB)
F-62256 (Word Fillable)
A-5 Request for Title XIX Care Level Determination Addendum for Developmentally Disabled Client
F-62256A (PDF Fillable, 76 KB)
F-62256A (Word Fillable)
A-6 COP Functional Screen (F20823) (PDF, 30 KB)
A-7 Brain Injury Waiver Level of Care (PDF, 23 KB)
A-8 Level of Care - Grid (PDF, 6 KB)
A-9 Assessment Tool (LTCFS Supplement) F20980 (Word Fillable)
A-10 Institutional Levels of Care: Children's Long-Term Support Programs in Wisconsin  (PDF, 134 KB)


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Last Revised: December 29, 2016