State Hearing Decision - Hearing Decisions
State Hearing Decision - Hearing Decisions
State Hearing Decision - Hearing Decisions
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STATE HEARING DECISION CONTINUATION<br />
Appellant’s Exhibits<br />
1. <strong>State</strong> hearing request<br />
2. Individualized Services Plan (ISP), 4 pages<br />
Appendix<br />
Warren County BODD’s Exhibits<br />
A. Appeal summary<br />
B. OAC 5123-2-9-01 HCBS waivers – Enrollment and disenrollment, 6 pages<br />
C. ODMR/DD Notification of Individual Change in Status<br />
D. Warren County BODD Withdrawal/Exit Report<br />
E. <strong>State</strong> hearing request<br />
F. Individualized Services Plan (ISP), 7 pages<br />
G. Personal Representative Designation Form<br />
H. Individual Input form, 2 pages<br />
I. Acknowledgement of Receipt of Notice of Privacy Practices<br />
J. Self-Administration Assessment, 2 pages<br />
K. Functional Assessment: Ages 16 and Above, 3 pages<br />
L. Level of Care Review, 2 pages<br />
M. Health Insurance Information and Authorization<br />
N. Residential Needs Assessment, 6 pages<br />
O. Cover Letter with Circle of Support and miscellaneous information, 49 pages<br />
P. Warren County BODD Waiting List Questionnaire/Assessment<br />
Q. Level One waiver information, 7 pages<br />
R. Ohio Revised Code 5126.055 Services provided by board that has Medicaid local<br />
administrative authority, 3 pages<br />
Page 5 of 5
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