Forms

Billing Manuals

• FY25 Billing Manual (PDF)
  • FY25 Billing Communication and FAQs to Providers (PDF)
• FY24 Billing Manual (PDF)  
• FY23 Billing Manual (PDF) 

Rate Tables 

• FY25 Rate Table (PDF)
• FY24 Rate Table (PDF) 

Tier Packages

• FY25 Annual Funding Levels (Tier Package) in English (PDF) and Spanish (PDF)
• FY24 Annual Funding Levels (Tier Package) in English (PDF) and Spanish (PDF)

​​​​​​Purchase Order Templates

• FY24 Purchase Order Template (xlsx)
• FY23 Purchase Order (xlsx)
• Home Health Agency Purchase Order (xlsx)

Allocation Forms

• Request to Change Respite Allocation (PDF)
• Self-Direct Reallocation for Transportation Form (xlsx)
• Request to Change Transportation Allocation (xlsx) 

Important Notice for All Forms 

Please do not use a highlighter on records. When records are uploaded, the highlighted information is actually grayed out which makes it more difficult to read. The Division thoroughly reads all records but if you feel you must highlight something, please just put an asterisk (*) near the relevant information.

DDD Eligibility Forms

• Visit the DDD Eligibility webpage 

Medicaid Waiver Application

Have Medicaid or SSI

• Application Coversheet (PDF)
• Blank Recertification (PDF)
• CP-1 Eligibility Assessment Level of Care (PDF)
• CP-12 Form (Word)
• Release of Information - Medical (DHS-25-M) (PDF)
• Release of Information (DHS-25) (PDF)

Do not already have Medicaid

• Application Coversheet (PDF)
• CP-1 Eligibility Assessment Level of Care (PDF)
• CP-12 Form (Word)
• DHS-2 Application (PDF)
• Release of Information - Medical (DHS-25-M) (PDF)
• Release of Information (DHS-25) (PDF)

ISP Template 

• CFCM Person-Centered Plan Form Template (PDF)
• Person Centered Plan Signature Page (Word)

Individualized Planning Tools

• DD ISP Submission Requirements (PDF)
• ISP Addendum/Amendment Form (PDF): Please submit this form with any changes to a current ISP or PO.
• Emergency Data Form (PDF): Be sure to send any personal information through an encrypted or secure email
• NCAPPS Promising Practices for Person-Centered Plans (PDF): read this booklet to learn more about what a good person-centered plan looks like

Employment Forms

• Employment and Earnings Reporting Form (web form)
• Targeted Employment Funding Request Form (web form)
• Targeted Employment Plan Form (PDF)

Variance Forms

• Variance Submission and Review instructions (PDF)
• Variance for Integrated Day Services Only (PDF)
• Variance to Work in a Segregated Employment Setting (PDF)

Supplemental Funding Forms 

• S106 Form for emergent need changes (PDF)
• S109 Form for nonemergent need changes (PDF)
• Quick Extension Form S109 and S106 HM fillable form (PDF)
• L9 Conversion Worksheet FY23 new rates in Excel or worksheet in PDF

• Consultation/Referral Form (PDF)
• Request for Petition for Instructions (PDF)

Forms and Rubrics

• CFCM 1-Month Monitoring Form 2024 (PDF)
• CFCM 6-Month Monitoring Form 2024 (PDF)
• CFCM/IF Annual Life Domains Form (PDF)
• CFCM/IF Roles and Responsibilities (PDF)
• CFCM/IF Plan Review Rubric (PDF)
• Pre-Planning and Quality Review Rubric (PDF)
• CFCM/IF Creating A Personal Profile (PDF)
• CFCM/IF Life Domains - Part 1 (PDF)

Letters

• CFCM/IF BHDDH Case Manager Introduction Letter (Word)
• CFCM/IF Intro Letter Spanish (Word)
• CFCM/IF DD Meeting Confirmation Letter with WS Merge Codes (Word)
• CFCM/IF DD Meeting Confirmation Letter with Other Invitees WS Merge Codes (Word)

FAQ

• CFCM FAQ 2025