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, and Forms
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. 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).
Self-Direction Tools for Case Managers can be found on the Self-Direction Services page under Self-Direction 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 Behavioral Health case managers /care coordinators who do not have access to the materials, assessments, and/or other information in our electronic record system (called Evergreen.) Access to Evergreen is not required to support people to apply for or access Waiver Services. These PCP Forms are used for ALL waiver processes.
Please click on the arrow to the left of the process to open the list of Protocols and Forms for each process below. When available, copies of PowerPoint presentations with more detailed instructions and examples are included.
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Waiver Protocols & Forms for Developmental Disability Services Case Managers
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Protocols
- Accepting or Declining a Waiver Offer Protocol (Word)
- Waiver Waiting List Protocol for Section 21 (Word)
- Voluntary Termination of Waiver Protocol (Word)
- Request for Exceptions for Section 21 (video)
- Request for Exceptions for Section 21 (PowerPoint)
- Coordination of Waiver Services with the Bureau of Rehabilitation Services Guidance (Word)
Forms
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Clinical Review Team (CRT) Guidelines and Forms for Case Managers and Providers
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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)
- Part A - Home Support Frequency Tool (Word)
- Part B - Home Support Frequency Tool (Word)
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Waiver Protocols & Application Forms for Children's & Behavioral Health Case Managers
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Protocols
- 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)
Section 21 and Section 29 Waiver Application Forms
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Initial Classification Forms for Children's & Behavioral Health Case Managers
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- Members Seeking Services Form
- Members Seeking Employment Services Form
- Providers Offering Capacity Form
- Service Implementation Plan (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)
- Financial Cap on Services Calculator (Excel)
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Annual Reclassification Forms for Children's & Behavioral Health Case Managers
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Changes in Waiver Service for Children's & Behavioral Health Case Managers
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Members Seeking Services (Vendor Call) Forms
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Other Waiver-Related Forms
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Other Forms and Resources