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NM DD Waiver Outside Reviewer Cover Sheet
Date:
Last Name:
Mailing Address:*
Agency:
End/Close a service
Decreasing units
Transfer to/from Mi Via*
RFI Response
Case Manager:
Send to UNM Continu
Annual Additional Notes:
XX DDW Behavi
XX DDW Residen
Additional Information- Naming convention examples: XX DDW ISP Annual 2019 2020
City
Guardian’s Information Last Name:
Address:
Cit
Revisions
ISP Begin Date:
*Please provide mailing address where OR will send individuals
Additional Notes:
REF# (cut/paste from RFI email)
Individual’s Information No LCA Change: Prio
LCA Change: Prior Y
3 Day Imminen
5 Day Imminent
Retro - M sent through DDSD Crisis Supports
*see note at end of coversheet
*see note at end of coversheet
Revision #
Explain Revision:*include PA begin and end dates
“When applicable, include justification for imminent requests in
t
Emai
Initial Eval
Increasing uni
LCA change*
XX DDW EXX DDW IS
First Name:
ISP End D
um of Care via CIS
oral
tial
:
y:
Phone
First Name:
RFI and Budget dete
r Yr/Current Billa
r/Current Billable
text box below or by a
State: NM
l:
ts
Adding ne
Provider ID
Closing BW
mployment P Rev# N
State:
ate:
CO HSC-CORE@sa
:
rminations
Close PA
ble PA
PA
dditional letter. Docum
Zip:
InitialNew C
w service(s)
correction only
S*
ote XX refers to the D
Zip:
lud.unm.edu
PrevioLivinolder
O
ents submitted must su
ust be
AllocCS/C
D Wa
Tr
OR
us reg, cat
pen P
pport
DOB:
ationIE service (PCA N/A)
iver recipient’s initials
ansfer/Change provider
v1.4b 02/01/19
cipient of Supported egory H and 55 or
A
justification.”