Objective Written Documentation Form

Objective Written Documentation is required when an Employer of Record hires an Attendant who resides in the same home as the Individual. This form may be completed by the Service Facilitator and submitted with the Service Authorization Request.

Individual Name*

Live in Employee Name*

12VAC30-122-120:Providers of services under any of the DD Waivers shall not be parents or guardians of individuals enrolled in the waiver who are minor children, or in the case of an adult enrolled in the waiver, the adult individual's spouse. Payment shall not be made for services furnished by other family members who are living under the same roof as the individual receiving services unless there is objective, written documentation, as defined in this subsection, as to why there are no other providers available to provide the care. Such other family members, if approved to provide services for the purpose of receiving Medicaid reimbursement, shall meet the same provider requirements as all other licensed providers. "Objective, written documentation" means documentation that demonstrates there are no persons available to provide supports to the individual other than the unpaid family/caregiver who lives in the home with the individual.

Please indicate which of the following criteria is met:*

1. Unable to hire staff (supporting documentation required)2. Special behavioral needs documented in the record3. Special medical needs documented in the record that do not require skilled care4. Language is a factor in service delivery (documented in the record)5. Other (*must meet regulatory compliance)

If you have selected 1. Unable to hire staff, please upload one of following: a. Copies of advertisements, b. copies of interview notes, or c. documentation indicating high turnover of staff:*

If you have selected 2. Special behavioral needs documented in the record, please upload supporting documentation.*

If you have selected 3. Special medical needs documented in the record that do not require skilled care, please upload supporting documentation.*

Which of the following does this documentation support?*

Behavioral supports are in place/current plan is effective.A referral for behavioral supports has been made.

Language Spoken:*

If you have selected 5. Other (*must meet regulatory compliance), please select which of the following reasons best describes your situation:*

The following backup plan is in place (name of Emergency Backup)*

Employer of Record EOR Name*

Signature*