№ lp_1_2_26944
File format: docx
Character count: 5215
File size: 87 KB
The document provides a form for requesting disenrollment from the Community Care Program or Supports Program, detailing procedures for voluntary disenrollment, failure to meet monitoring requirements, psychiatric admission, incarceration, Medicaid ineligibility, and other relevant situations.
Year:
2023
Region / City:
New Jersey
Topic:
Disenrollment from DDD Programs
Document Type:
Request Form
Institution:
Division of Developmental Disabilities (DDD)
Author:
DDD Support Coordinator
Target Audience:
Individuals enrolled in DDD programs, legal guardians, DDD staff
Effective Period:
Not specified
Approval Date:
Not specified
Date of Modifications:
Not specified
Price: 8 / 10 USD
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The product description is provided for reference. Actual content and formatting may differ slightly.
Year:
Not specified
Region / City:
District of Columbia
Topic:
Mental Health Services
Document Type:
Form
Organization / Institution:
Government of the District of Columbia, Department of Behavioral Health
Author:
Not specified
Target Audience:
Adults seeking Mental Health Rehabilitation Services
Effective Period:
Not specified
Approval Date:
Not specified
Modification Date:
Not specified
Year:
2025
Region / City:
Wisconsin
Topic:
Health Services
Document Type:
Form
Organization:
Department of Health Services, Division of Public Health
Author:
Department of Health Services
Target Audience:
Managed Care Organizations, IRIS Consultant Agencies, PACE Organizations, Bureau of Quality & Oversight
Period of Effectiveness:
N/A
Approval Date:
N/A
Amendment Date:
N/A
Contextual Description:
Form used by organizations to request disenrollment from the Family Care, PACE, Partnership, and IRIS programs in Wisconsin.
Year:
Not specified
Region / City:
Not specified
Subject:
Involuntary disenrollment from the Health Home program
Document Type:
Procedure/Guideline
Organization / Institution:
Not specified
Author:
Not specified
Target Audience:
Health Home Care Coordinators, Lead
Effective Period:
Not specified
Approval Date:
Not specified
Date of Changes:
Not specified
Contextual Description:
Procedure for handling involuntary disenrollment from the Health Home program due to beneficiary behaviors or environmental concerns.
Country:
United States
State:
Wisconsin
Issuing Body:
Department of Health Services, Division of Medicaid Services
Program:
IRIS (Include, Respect, I Self-Direct)
Form Number:
F-01319
Edition Date:
02/2017
Document Type:
Administrative request form
Subject:
Involuntary disenrollment of IRIS participants
Legal Reference:
Wisconsin State Statute; IRIS Work Instruction Manual Section 7.1A.1
Target Group:
IRIS Consultant Agencies (ICAs)
Applicable Reasons for Disenrollment:
No Spend; No Contact; Health and Safety; Residing in an Ineligible Living Setting; Substantiated Fraud; Mismanagement of Budget Authority; Mismanagement of Employer Authority; Refusal to Comply with IRIS Program Requirements
Sections:
Demographics; Reason for Request; Explanation of Attempted Mitigation Strategies; Conclusion; Applicable to No Contact or No Spend Only
Signature Requirement:
IRIS Consultant Agency Representative
Personal Data:
Participant’s name, MCI, contact history, expenditure information
Year:
2016
Region:
United States and Overseas
Subject:
Health Care Enrollment and Management
Document Type:
Government Form
Agency:
Department of Defense
Author:
Defense Health Agency
Intended Audience:
Active duty service members, retirees, and eligible family members
Effective Period:
Ongoing until updated
Approval:
OMB No. XXXX-XXXX
Previous Edition:
Obsolete
Form Number:
DD Form 2876-3
Application Methods:
Online, Telephone, Paper Submission
Privacy Regulations:
HIPAA, 10 U.S.C. 1079 and 1086, 38 U.S.C. Chapter 17
Year:
2019
Region / City:
United States
Topic:
Immigration Services
Document Type:
Instruction Manual
Organization:
U.S. Citizenship and Immigration Services (USCIS)
Author:
U.S. Citizenship and Immigration Services
Target Audience:
Individuals applying for immigration benefits
Effective Period:
Ongoing, with periodic updates
Approval Date:
10/15/2019
Date of Changes:
10/15/2019
Note:
Year
Region / City:
Colorado
Topic:
Family Violence Option, Cash Assistance, Work Activities
Document Type:
Policy
Organization / Institution:
Colorado Department of Human Services
Target Audience:
State employees, public, relevant stakeholders
Year:
2023
County:
[County Name]
Club:
[Club Name]
Location of Activity:
[Location Name]
Date of Activity:
[Date]
Participant Name:
[Participant Name]
Participant Age:
[Participant Age]
Participant is a 4-H member:
Yes/No
Participant is NOT a 4-H member:
Yes/No
Participant knows how to swim and can swim at least one length of the pool:
Yes/No
Participant does NOT know how to swim:
Yes/No
Participant does NOT have permission to participate in water activities:
Yes/No
Governing Law:
Iowa
Program:
[Program Name]
Health Requirements:
Participant must be healthy and reasonably fit to participate safely
Inherent Risks:
Climbing, Ropes Course, Swimming
Emergency Contact:
[Emergency Contact Name]
Signature of Parent or Guardian:
[Signature]
Date:
[Date]
Signature of Participant:
[Signature]
Year:
2014
Region / City:
United States
Subject:
Research ethics, IRB review process
Document type:
Checklist
Author:
Not specified
Target audience:
IRB members, Designated Reviewer, researchers
Period of validity:
Ongoing
Approval date:
3/25/14
Amendment date:
11/1/2024
Year:
2023
Region / City:
Bemidji
Topic:
Liability Waiver, Sports Facility
Document Type:
Legal Agreement
Organization / Institution:
Bemidji Indoor Sports Commission
Author:
Not specified
Target Audience:
Participants of the Neilson Fieldhouse, parents/legal guardians of minors
Period of validity:
Not specified
Approval Date:
Not specified
Modification Date:
Not specified
Year:
2024
Region / City:
Georgia
Theme:
Health care, Medicaid services, Waiver programs
Document Type:
Program Update
Agency / Organization:
Georgia Department of Community Health (DCH)
Author:
Vonnie Stelly, Andrea Streeter, Briana Coogler, Marina Kim, Shandria Beasley, Taesha Ward, Donna Elrod, Sharon Collins
Target Audience:
Health care providers, Medicaid providers, Waiver program administrators
Period of Validity:
Ongoing
Approval Date:
07/01/2024
Amendment Date:
Ongoing
Note:
Year
Theme:
Home and Community-Based Waiver, Brain Injury Care
Document Type:
Policy Guide
Institution:
Department of Health and Human Services (DHHS)
Target Audience:
Adults with brain injuries, caregivers, healthcare providers
Year:
2025
Region / City:
England and Wales
Topic:
Criminal record check waiver for Call to the Bar applicants
Document type:
Guideline
Institution:
Bar Standards Board (BSB)
Author:
Bar Standards Board
Target audience:
Inns’ student members applying for Call in 2025, transferring qualified lawyers
Period of validity:
2025
Approval date:
Not specified
Date of changes:
Not specified
Note:
Year
Year:
2023
Region / City:
Texas
Subject:
Construction and payment waiver
Document Type:
Legal Affidavit
Organization / Institution:
Texas General Land Office (GLO)
Author:
Texas General Land Office
Target Audience:
Contractors and subcontractors in construction projects
Period of Validity:
N/A
Approval Date:
N/A
Date of Modifications:
N/A
Type of document:
Referral form and liability waiver
Organization:
Community Warehouse Project (CWP) of Cheater County
Jurisdiction:
Commonwealth of Pennsylvania
Intended audience:
Clients receiving furniture through an agency referral
Related roles:
Agency case managers and sponsors
Subject matter:
Furniture and home goods delivery and acceptance
Condition of goods:
Used items provided as-is without warranties
Return policy:
Furniture and home goods cannot be returned to CWP
Client obligations:
Acceptance of all delivered furniture and preparation of residence for delivery
Risk allocation:
Assumption of all risks related to acceptance, transportation, and use
Legal provisions:
Release, indemnification, and hold harmless agreement
Age requirement:
Client is 18 years of age or signs as parent or guardian of a minor
Language assistance:
Client responsible for bringing a translator if needed
Form requirements:
Three forms required to be completed and submitted at time of request
Jurisdiction:
State of Kansas
Legal basis:
K.S.A. 75-5276; K.S.A. 75-5277; K.S.A. 76-769
Issuing body:
Kansas Correctional Industries
Document type:
Administrative waiver request form and statutory guidance
Subject matter:
Mandatory procurement and waiver process for office furniture and related goods
Affected entities:
State agencies of Kansas
Exempt entities:
Universities in Kansas
Goods covered:
Office furniture, office systems, paint, janitorial products
Waiver decision authority:
Kansas Correctional Industries; Secretary of Administration; Director of Purchases
Decision timeframe:
Five working days from receipt
Appeal authority:
Secretary of Administration and Director of Purchases
Applicable standards:
Comparable quality, price, and timeliness
Geographic scope:
Kansas
Year:
2023
Region / City:
Maynooth, Co. Kildare
Topic:
Academic Procedure
Document Type:
Form
Institution:
Maynooth University
Author:
Not specified
Target Audience:
Students in postgraduate programs
Period of Validity:
Not specified
Approval Date:
Not specified
Date of Changes:
Not specified
Note:
Year
Document Type:
Waiver Form
Organization / Institution:
Diocese of Allentown
Target Audience:
Parents/Guardians of Students
Year:
2023
Region / City:
United States
Subject:
Survey requirements waiver for Freddie Mac Multifamily transactions
Document Type:
Policy/Guideline
Organization / Institution:
Freddie Mac
Author:
Freddie Mac
Target Audience:
Sellers/Servicers in Freddie Mac Multifamily program
Effective Period:
Ongoing
Approval Date:
8-17-2023
Date of Changes:
8-17-2023