New Choices Waiver

Case Management Agency Resources

This tab contains forms and other resources intended only for case management agencies (CMAs) that are contracted with the New Choices Waiver program. Other types of New Choices Waiver providers are not permitted to complete these forms as they are only ​valid and ​accepted when completed by CMA representatives. If other entities believe that one of these forms should be completed for a particular New Choices Waiver client, they must contact the client's chosen CMA to request it.

Case Management Agency Forms and Documents:

​CMAs are permitted to print these forms for use with their New Choices Waiver clients. These are PDF copies and are not typable. Some of the forms are available in Word format, but not on this website. If a case manager would like a Word copy of a particular form, please contact the New Choices Waiver program office to request it.

This is NOT an all-inclusive list of required forms for New Choices Waiver CMA providers. There are additional forms that CMAs are required to complete for their waiver clients that will not be posted on this website. (Examples include Service Authorization Forms, Freedom of Choice of Providers Forms, SAS forms, etc). If a CMA needs to obtain any of the other forms that do not appear in this list, please contact the New Choices Waiver program office.

Documents:

114AR DWS Release Form July 2016.pdf

Approved CMA NOD January 2015.pdf

CMA Fax Cover Sheet 10.15.2016.pdf

Disenrollment Form DPF-1 5.31.17 .pdf

DPF-2 Special Circumstance Involuntary Disenrollment Request 1-1-15.pdf

Health and Safety Agreement Template 2014.pdf

Health Status Screening Report Effective 4.11.13.pdf

LOC Determination Form NCW 1.21.2014.pdf

Memory Care Checklist Effective 10.12.17.pdf

Rental Agreement Template 7.1.15.pdf

Rights and Responsibilities-Final Effective 7-1-15.pdf

NCW PCCP Addendum Effective July 1, 2016.pdf