Title 480 Home and Community-Based Waiver Services and Optional Targeted Case Management Services Appendix

 
3
Statutes & Regs
Operational
 
No
No

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What you need to know

What you need to know

​Number Name
480-000-2Form MILTC-13AD, “Child/Client's Level of Care"
480-000-4Form MILTC-14AD, “Functional Criteria"
480-000-6Form MILTC-7AD, “Child's Functional Assessment and Family Support ​Survey"
480-000-7Form MILTC-40, “Child's Functional Nutrition Assessment"
480-000-8Form MILTC-2AD, “Adult Assessment Form"
480-000-10Form MILTC-5AD, “Consent Form"
480-000-12Form MILTC-12AD, “Plan of Services and Support"
480-000-13Form MILTC-15AD, “Waiver Plan Worksheet"
480-000-14(Reserved)
480-000-15Form DA-6 and DA-6-S, “Request for Fair Hearing" 
480-000-16Form MC-73, “Time Assessment and Service Plan"
480-000-20Form MC-19, “Nebraska Service Provider Agreement"
480-000-20 iForm MC-19-I, “Instructions for Form MC-19"
480-000-21Form MC-190, “Nebraska Service Provider Agreement Provider Addendum"
480-000-26(Reserved)
480-000-27Form MC-9AD, “Prior Authorization for Assisted Living Services"
480-000-28(Reserved)
480-000-30Form MILTC-21, “Client Consent for Multiple Occupancy"
480-000-32(Reserved)
480-000-34Form CRED-0363, “Children's Record"
480-000-36(Reserved)
480-000-38(Reserved)
480-000-39Form MILTC-71, “Home Again Sponsor Expense Record"
480-000-40(Reserved)
480-000-42(Reserved)
480-000-44(Reserved)
480-000-46(Reserved)
480-000-48(Reserved)
480-000-49Form MC-36-ES, “Individual Transportation Provider Record of Services"
480-000-50Form HHS-6 and HHS-6-S (form only), “Notice of Action"
480-000-52Form FA-65 and FA-65-S (form only), “Appointment of DHHS as Agent"
480-000-54Form MC-199, “Provider Release of Information, Felony/Misdemeanor Statement"
480-000-55Form MILTC-61, “Potential Conflict of Interest Disclosure Statement"
480-000-56Form IRS W-9, “Request for Taxpayer Identification Number and Certification"
480-000-58Form IRS W-4, “Employee's Withholding Allowance Certificate"
480-000-60(Reserved)
480-000-61Form MC-37-ES, “Individual Provider Record of Services"
480-000-501 Nebraska Medicaid Aged and Disabled Waiver Fee Schedule for Non-Medical Transportation Services