Enhanced Supervision Form

This form was first distributed for discussion at the June 10, 2009 Task Force meeting, and was subsequently issued electronically on July 23, 2009.   We were originally told that this form must accompany any waiver request for enhanced supervision in the ICFs/MR; however, ODP soonafter stated that it was not required.  The form is included here to provide ideas for you on the types of information you should include in your request even if not using this form.  

Before/After Profiles

Before and After Profiles are required for waiver requests related to  change in client characteristics.   The dates of the profiles should coincide with the point in time that the profile reflects.  For instance, if the profiles are prepared based on a previous IHP or ISP and a current IHP or ISP, then use the date of the IHP/ISPs.   The date of the before profile should be "before" the waiver condition occurred, and the date on the after profile should be on or after the date the change occurred.   AZTAC recommends that you prepare an updated client profile everytime the IHP or ISP is updated, at least  annually or due to a change.  The differences (i.e., additional needs) between the two documents are scrutinized by ODP in the review of your request.

Form for submitting a waiver request for additional direct care

This form was distributed at the September 9, 2009 ICF/MR Task Force with an effective date of September 14, 2009.    ODP stated they will send the form electronically with instructions on its use. However, the form was not implemented and is not required as of this writing in 2019.  The form is included here because it was indeed issued by ODP and it at least provides insight on the types of information you might include in your request.

Form for submitting a waiver request for additional nursing 

This form was distributed at the September 9, 2009 ICF/MR Task Force with an effective date of September 14, 2009.  ODP stated they will send the form electronically with instructions on its use; however, the form was not implemented and is not required as of this writing in 2019.  The form is included here because it was issued by ODP and it at least provides insight on the types of information you might include in your request.