| Number |
Name |
| 480-000-2 |
Form MILTC-13AD, “Child/Client’s Level of Care” |
| 480-000-4 |
Form 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 |
Form 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 |