These protocols and forms are used by Case Managers supporting adults with Intellectual or Developmental Disability (IDD) and/or Autism, as well as Children’s and Mental Health Case Managers supporting adults who utilize MaineCare Benefits Manual Sections 21 and 29 waiver programs.
Protocols & Instructions
The following documents help guide Case Managers to access resources available to the individuals and families they support, including how to complete various forms and submit initial classification packets, changes in service/authorization requests, Clinical Review Team requests, and annual reclassification packets.
This page also includes Person-Centered Planning forms for case managers who do not have access to members’ records in EIS. When available, copies of PowerPoint presentations with more detailed instructions and examples are included.
Self-Direction Tools for Case Managers can be found on the Self-Direction Services page under Self-Direction Resources.
General Developmental Disability Services Case Management Protocols
- Emergency Transitional Housing: A Guide for Case Managers Supporting Adults with Intellectual Disabilities and Autism (PDF)
- Family Support Protocol (Word)
- Professional Services Protocol (Word)
- Reportable Events Instruction (Word)
- Writing Case Management Notes in EIS (PowerPoint)
- Information for People Receiving Developmental Services and Their Families or Guardians (Word) | also in PDF
- Closing Case Management Services Desk Level Procedure (PDF)
Waiver Protocols for Developmental Disability Services Case Managers
- Waiver Application Protocol (Word)
- Waiver Initial Classification (Word)
- Waiver Reclassification Protocol (Word)
- Waiver Service Proposal Process Protocols (Adding or Changing a Service) (Word)
- Waiver Change in Service Protocol (Word)
- Accepting or Declining a Waiver Offer Protocol (Word)
- Waiver Waiting List Protocol for Section 21 (Word)
- Voluntary Termination of Waiver Protocol (Word)
- How To View & Print a Report 360: Summary of Authorized Services (SAS) in EIS (PDF)
- Request for Exceptions for Sections 21 and 29 (video)
- Request for Exceptions for Section 21 (PowerPoint)
- Coordination of Waiver Services with the Bureau of Rehabilitation Services Guidance (Word)
Waiver Protocols for Children's & Mental Health Case Managers
- Children's & Mental Health Section 21 & Section 29 Waiver Application Process (PDF) – This is a PowerPoint outlining details and examples to assist in completing Section 21 and Section 29 Waiver Applications.
- Waiver Application Protocol for Sections 21 & 29 Children's and Mental Health Case Management (Word)
- Accepting or Declining a Waiver Offer Protocol (Word)
- Initial Classification for Sections 21 & 29 Children's and Mental Health Case Management (Word)
- Waiver Reclassification Protocol (Word)
- Waiver Service Proposal Process Protocol (Adding or Changing a Service) (Word)
- Section 21 Annual Waitlist Notification Protocol (Word)
Clinical Review Team (CRT) Guidelines for Case Managers and Providers
Please note that the following services are only available for members on Section 21 except for Assistive Technology
- Assistive Technology Request Guidelines (Word)
- Crisis Intervention Services CCM Technical Guide Revised (Word)
- Increased Level of Supports for Shared Living Family Centered Support Request Guidelines (Word)
- Medical Add On Authorization Requests Guidelines (Word)
- Specialized Medical Equipment and Supplies Request Guidelines (Word)
- T2016-Guidelines-for-Authorization-Requests (Word)
Provider Protocols
Forms
All forms on this page are for case managers to use as templates. Please note that some forms must be saved in Word and cannot be scanned and emailed as an attachment. Forms in Excel must be saved in Excel or scanned and sent as an attachment (in PDF format).
General Forms for Developmental Disability Services Case Managers
- DHHS Release of Information (Word)
- Case Management Referral Form (Word)
- Agency Permission for Services Form (PDF)
- Professional Services Request Form (Word)
- Written Order Form- Final (Word)
- Written Order Form - Fillable (Word)
- Payment Info Form (Word)
- EIS New User Form (Word)
- Case Coordination Unit Referral Form (Word)
- Self-Direction Exploration Tool (Word)
Waiver Forms for Developmental Disability Case Managers
- Section 21 Waiver Information Form (Word)
- Section 29 Cover Sheet (Word)
- Yearly Cost Estimate for Services (Excel)
- Choice Letter (Word)
- Financial Cap on Services Calculator (Excel)
- Authorization Request Form (Word)
- Authorization Request Form (PDF)
- Ancillary Service Proposal Form (Word)
- Declination-Voluntary Termination of Waiver Services Form (Word)
- Weekly Schedule (Excel)
- Request for Exceptions Form (Word)
- Long Term Work Support Transfer Form (Word)
- Members Seeking Services Form
- Members Seeking Employment Services Form
- Providers Offering Capacity Form
Waiver Forms for Children's & Mental Health Case Managers
Section 21 and Section 29 Waiver Application Forms
- Section 29 Cover Sheet (Word)
- Section 21 Waiver Information Form (Word)
- Developmental Services Home and Community Based Waiver Assessment (BMS-99) (Word)
- Personal Plan Update (Word)
- Yearly Cost Estimate for Services (Excel)
Initial Classification Forms
- Members Seeking Services Form
- Members Seeking Employment Services Form
- Providers Offering Capacity Form
- Service Proposal Request Form (Word)
- Personal Plan Update (Word)
- Choice Letter (Word)
- Developmental Services Home and Community Based Waiver Assessment (BMS-99) (Word)
- Authorization Request Form (Word) (PDF)
- Declination-Voluntary Termination of Waiver Services Form (Word)
- Weekly Schedule (Excel)
Annual Reclassification Forms
- Personal Plan Update (Word)
- Service Proposal Request Form (Word)
- Developmental Services Home and Community Based Waiver Assessment (BMS-99) (Word)
- Authorization Request Form (Word) (PDF)
Other Waiver Related Forms
- Financial Cap on Services Calculator (Excel)
- Ancillary Service Proposal Form (Word)
- Authorization Request Form (Word) (PDF)
- Declination-Voluntary Termination of Waiver Services Form (Word)
- Service Proposal Request Form (Word)
- Weekly Schedule (Excel)
Other Forms and Resources
Person Centered Planning Forms
Person Centered Plan Manual (Word)
- Personal Plan Face Sheet (PDF)
- Personal Plan Narrative (PDF)
- MaineCare Service Description - Home Supports (PDF)
- MaineCare Service Description - Community Supports (PDF)
- MaineCare Service Description - Work/Employment Supports (PDF)
- MaineCare Service Description - Case Management (PDF)
- Service Provider Goals Description (PDF)
- EIS PCP User Manual (PDF)
- OADS PCP Agreement Sheet (Word)
- Grievance Appeal Insert Card (Word)
- Grievance and Reportable Event Printable Bi-Fold (Word)
- HCBS Requirements Modification Addendum (Word) and Decision Tree (PPT) for Section 21/29
Agency Resources
Please see the section on Clinical Review Team Guidelines for more information on the services the CRT approves before prior authorizations are entered.
PCP Forms are used by Children’s and Mental Health case managers who do not have access to the PCP assessment in Evergreen. They will need you to complete these pages for Initial Classifications, annual service plans, and Changes in Service requests.