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

Appendix

Number Name
480-000-2 Form MILTC-13AD, “Child/Client’s Level of Care”
480-000-4 F​orm MILTC-14AD, “Functional Criteria”
480-000-6 ​Form MILTC-7AD, “Child’s Functional Assessment and Family Support   Survey”
​480-000-7 ​Form MILTC-40, “Child’s Functional Nutrition Assessment”
480-000-8 ​Form MILTC-2AD, “Adult Assessment Form”
​480-000-10 ​Form MILTC-5AD, “Consent Form”
​480-000-12 ​Form MILTC-12AD, “Plan of Services and Support”
480-000-13 ​Form MILTC-15AD, “Waiver Plan Worksheet”
480-000-14 ​Form MILTC-35, “Respite Unit Calculation Form”
480-000-15 ​Form DA-6 and DA-6-S, “Request for Fair Hearing” 
480-000-16 ​Form MC-73, “Time Assessment and Service Plan”
480-000-20 ​Form MC-19, “Nebraska Service Provider Agreement”
480-000-20 i ​Form MC-19-I, “Instructions for Form MC-19”
480-000-21 ​Form MC-190, “Nebraska Service Provider Agreement Provider Addendum”
​480-000-26 ​Form MC-196, “Adult Day Services Provider Addendum”
480-000-27 ​Form MC-9AD, “Prior Authorization for Assisted Living Services”
480-000-28 ​Form MC-191AD, “Assisted Living Service Provider Addendum”
​480-000-30 ​Form MILTC-21, “Client Consent for Multiple Occupancy”
480-000-32 ​Form MC-192AD, “In-Home and License-Exempt Family Child Care Home Addendum”
480-000-34 ​Form CRED-0363, “Children’s Record”
480-000-36 ​Form MC-195, “Chore/PAS Provider Addendum”
480-000-38 ​Form MC-194AD, “Home Again Sponsor Addendum”
​480-000-39 ​Form MILTC-71, “Home Again Sponsor Expense Record”
480-000-40 ​Form MC-217AD, “Independence Skills Management Provider Addendum”
480-000-42 ​Form MC-197, “Meals Provider Addendum”
480-000-44 ​Form MC-193AD, “Personal Emergency Response System Provider Addendum”
480-000-46 ​Form MC-198, “Respite Provider Addendum”
480-000-48 ​Form MC-211, “Non-Emergency Transportation Addendum”
480-000-49 ​Form MC-36-ES, “Individual Transportation Provider Record of Services”
480-000-50 ​Form HHS-6 and HHS-6-S (form only), “Notice of Action”
480-000-52 ​Form FA-65 and FA-65-S (form only), “Appointment of DHHS as Agent”
480-000-54 ​Form MC-199, “Provider Release of Information, Felony/Misdemeanor Statement”
480-000-55 Fo​rm MILTC-61, “Potential Conflict of Interest Disclosure Statement”
480-000-56 ​Form IRS W-9, “Request for Taxpayer Identification Number and Certification”
480-000-58 ​Form IRS W-4, “Employee’s Withholding Allowance Certificate”
480-000-60 ​Form DHHS-5-N, “N-FOCUS Billing Document”
480-000-61 ​Form MC-37-ES, “Individual Provider Record of Services”
480-000-501 Nebraska Medicaid Aged and Disabled Waiver Fee Schedule for Non-Emergency Transportation Services

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