Forms

Billing Manuals

• FY25 Billing Manual (PDF)
  • FY25 Billing Communication and FAQs to Providers (PDF)
• FY24 Billing Manual (PDF)  
• FY23 Billing Manual (PDF) 

Rate Tables 

• FY25 Rate Table (PDF)
• FY24 Rate Table (PDF) 

Tier Packages

• FY25 Annual Funding Levels (Tier Package) in English (PDF) and Spanish (PDF)
• FY24 Annual Funding Levels (Tier Package) in English (PDF) and Spanish (PDF)

​​​​​​Purchase Order Templates

• FY24 Purchase Order Template (xlsx)
• FY23 Purchase Order (xlsx)
• Home Health Agency Purchase Order (xlsx)

Allocation Forms

• Request to Change Respite Allocation (PDF)
• Self-Direct Reallocation for Transportation Form (xlsx)
• Request to Change Transportation Allocation (xlsx) 

DDD Eligibility Forms

• Visit the DDD Eligibility webpage 

Medicaid Waiver Application

Have Medicaid or SSI

• Application Coversheet (PDF)
• Blank Recertification (PDF)
• CP-1 Eligibility Assessment Level of Care (PDF)
• CP-12 Form (Word)
• Release of Information - Medical (DHS-25-M) (PDF)
• Release of Information (DHS-25) (PDF)

Do not already have Medicaid

• Application Coversheet (PDF)
• CP-1 Eligibility Assessment Level of Care (PDF)
• CP-12 Form (Word)
• DHS-2 Application (PDF)
• Release of Information - Medical (DHS-25-M) (PDF)
• Release of Information (DHS-25) (PDF)

ISP Template 

• CFCM Person-Centered Plan Form Template (PDF)
• Person Centered Plan Signature Page (PDF)

Individualized Planning Tools

• DD ISP Submission Requirements (PDF)
• ISP Addendum/Amendment Form (PDF): Please submit this form with any changes to a current ISP or PO.
• Emergency Data Form (PDF): Be sure to send any personal information through an encrypted or secure email
• NCAPPS Promising Practices for Person-Centered Plans (PDF): read this booklet to learn more about what a good person-centered plan looks like

Employment Forms

• Employment and Earnings Reporting Form (web form)
• Targeted Employment Funding Request Form (web form)
• Targeted Employment Plan Form (PDF)

Variance Forms

• Variance Submission and Review instructions (PDF)
• Variance for Integrated Day Services Only (PDF)
• Variance to Work in a Segregated Employment Setting (PDF)

Supplemental Funding Forms 

• S106 Form for emergent need changes (PDF)
• S109 Form for nonemergent need changes (PDF)
• Quick Extension Form S109 and S106 HM fillable form (PDF)
• L9 Conversion Worksheet FY23 new rates in Excel or worksheet in PDF

• Consultation/Referral Form (PDF)
• Request for Petition for Instructions (PDF)

Forms and Rubrics

• CFCM 1-Month Monitoring Form 2024 (PDF)
• CFCM 6-Month Monitoring Form 2024 (PDF)
• CFCM/IF Annual Life Domains Form (PDF)
• CFCM/IF Roles and Responsibilities (PDF)
• CFCM/IF Plan Review Rubric (PDF)
• Pre-Planning and Quality Review Rubric (PDF)
• CFCM/IF Creating A Personal Profile (PDF)
• CFCM/IF Life Domains - Part 1 (PDF)

Letters

• CFCM/IF BHDDH Case Manager Introduction Letter (Word)
• CFCM/IF Intro Letter Spanish (Word)
• CFCM/IF DD Meeting Confirmation Letter with WS Merge Codes (Word)
• CFCM/IF DD Meeting Confirmation Letter with Other Invitees WS Merge Codes (Word)

FAQ

• CFCM FAQ 2025