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

 

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Statutes & Regs

Operational

 

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​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	(Reserved)
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	(Reserved)
480-000-27	Form MC-9AD, “Prior Authorization for Assisted Living Services"
480-000-28	(Reserved)
480-000-30	Form MILTC-21, “Client Consent for Multiple Occupancy"
480-000-32	(Reserved)
480-000-34	Form CRED-0363, “Children's Record"
480-000-36	(Reserved)
480-000-38	(Reserved)
480-000-39	Form 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)
480-000-49	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	(Reserved)
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-Medical Transportation Services

 

Useful Links

• Medicaid Page
• Rules & Regulations Page

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