A1SC NHTD/TBI Waiver Referral Form
Please complete the referral form using the information from the PDF. All fields are optional unless otherwise noted in the form.
Participant and Referral Details
Waiver Type
TBI
NHTD
Date
-
Month
-
Day
Year
Date
Participant Name
Participant Address
Participant Telephone
Please enter a valid phone number.
Format: (000) 000-0000.
Medicaid CIN
DOB
-
Month
-
Day
Year
Date
Applicant Status
Pending Applicant
RRDC intake completed
Enrolled Participant
RRDC intake date scheduled for
-
Month
-
Day
Year
Date
Service Plan Dates
Most recent UAS date
-
Month
-
Day
Year
Date
Current Service Coordination Agency Name
Current Service Coordinator Name
Current Service Coordinator Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Current Service Coordinator Email
example@example.com
Current Concerns and Waiver Needs
Current Concerns
Memory loss
Forgetfulness
Confusion
Disorientation
Poor reasoning
Other
Current Concerns - Other 1
Current Concerns - Other 2
Assistance Needed from the Waiver
Money Management
Organization
Household maintenance
Community Inclusion
Travel Training
Other
Assistance Needed from the Waiver - Other 1
Assistance Needed from the Waiver - Other 2
Assistance Needed from the Waiver - Other 3
Current supports in the home
None
Personal Care Aides
Informal supports
Nursing
Other
Current supports in the home - Other 1
Current supports in the home - Other 2
Mode of Ambulation
Independent
Independent with oversight
Cane
Walker
Wheelchair
Other
Referral Source
Referral Source Name
Referral Source Agency
Referral Source Phone #
Please enter a valid phone number.
Format: (000) 000-0000.
Referral Source Email
example@example.com
Submit
Should be Empty: