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

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Provider ID

Closing BW

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Zip:

InitialNew C

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correction only

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ote XX refers to the D

Zip:

lud.unm.edu

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ents submitted must su

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ansfer/Change provider

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justification.”