Medicaid Home and Community-Based Waivers Manual - Appendix A

APPENDIX A: Level of Care

A-1 Adult Long Term Care Functional Screen, F-00366 (PDF)
A-2 Children's Long-Term Care Functional Screen
A-3 QMRP Definition (PDF)
A-4 Request for Title XIX Care Level Determination
A-5 Request for Title XIX Care Level Determination Addendum for Developmentally Disabled Client
A-6 COP Functional Screen, F-20823 (PDF)
A-7 Brain Injury Waiver Level of Care
A-8 Level of Care - Grid (PDF)
A-9 Assessment Tool: LTCFS Supplement, F-20980 (Word Fillable)
A-10 Institutional Levels of Care: Children's Long-Term Support Programs in Wisconsin  (PDF)

 

Last Revised: August 18, 2017