State Hearing Decision - Hearing Decisions

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STATE HEARING DECISION CONTINUATION Si usted quiere información sobre servicios legales gratuitos pero no sabe el número de su oficina local de servicios legales, usted puede llamar al Ohio State Legal Services Association, gratuitamente, al 1-800-589-5888, para el número local. Page 4 of 5
STATE HEARING DECISION CONTINUATION Appellant’s Exhibits 1. State hearing request 2. Individualized Services Plan (ISP), 4 pages Appendix Warren County BODD’s Exhibits A. Appeal summary B. OAC 5123-2-9-01 HCBS waivers – Enrollment and disenrollment, 6 pages C. ODMR/DD Notification of Individual Change in Status D. Warren County BODD Withdrawal/Exit Report E. State hearing request F. Individualized Services Plan (ISP), 7 pages G. Personal Representative Designation Form H. Individual Input form, 2 pages I. Acknowledgement of Receipt of Notice of Privacy Practices J. Self-Administration Assessment, 2 pages K. Functional Assessment: Ages 16 and Above, 3 pages L. Level of Care Review, 2 pages M. Health Insurance Information and Authorization N. Residential Needs Assessment, 6 pages O. Cover Letter with Circle of Support and miscellaneous information, 49 pages P. Warren County BODD Waiting List Questionnaire/Assessment Q. Level One waiver information, 7 pages R. Ohio Revised Code 5126.055 Services provided by board that has Medicaid local administrative authority, 3 pages Page 5 of 5
Page 1 and 2: OHIO DEPARTMENT OF JOB AND FAMILY S
Page 3: STATE HEARING DECISION CONTINUATION

State Hearing Decision - Hearing Decisions

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