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Developmental Disabilities Forms & Documents
If you need assistance:
Please see the Access and Services Management page for a list of personnel you can contact.
Available online documents:
Open them directly by clicking on them, or save them to disk (the easiest way on a PC is by right-clicking your mouse.) The files are in Word 2000, Excel 2000, and Adobe Acrobat 5.0 PDF files. Each document link is set to open in a new window. Some of these files are large and may take a few minutes to load or save - the file sizes are indicated in the table.
| Procedures | ||
| Communications | ||
| Updates and Bulletins | ||
| NC DMA Medicaid Durable Medical Equipment Fee Schedule (March 1, 2005) | ||
| NC DMA Home Health and Private Duty Nursing Maximum Reimbursement
Rate Schedule Effective Date: July 2004 Modified February 2005 |
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| NC DMA Home Infusion Therapy Maximum Reimbursement Rates Effective
Date: February 1, 2005 |
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| NC DMA Medicaid Rates for Orthotic and Prosthetic Devices Effective
January 1, 2005 |
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| Service Authorization Codes and Service Definitions | ||
| Guidelines for CAP-MR/DD can be found at this state site | ||
| DD Service Authorization (01/12/05) | Word File | PDF (215 Kb) |
| ASPM 1026 Service Definitions Manual (01/03) | PDF (2 MB) | |
| ASPM 45 Service Records Manual (09/03) | PDF (440 Kb) | |
| Plan of Care and Local Approval Plan | ||
| Person Centered Plan (mandatory for CAP-MR/DD and requested for general DD consumers). This file contains macros. | Word File (730 Kb) | |
| CAP-MR/DD Local Approval Plan | Word File | |
| Service Authorization Request Form (03/01/06) | Word File | |
| Description of the Initial Clinical Evaluation (09/01/04) | Word File | |
| Services NOT requiring authorization (11/01/05) | Word File | |
| Unit of Service Cheat Sheet | Word File | |
| DMA Memorandum Re: Rounding (01/24/04) | Word File | |
| Accessing CAP-MR/DD Equipment and Supplies (Waiver recipients only) | ||
| Case Manager Responsibilities to Access Equipment and Supplies | Word File | |
| Requisition for Equipment and Supplies | Word File | |
| Instructions for Completing Requisition | Word File | |
| CAP-MR/DD Service Authorization Request Form | ||
| CAP-MR/DD Service Authorization Form (03/03/05) | Word File | PDF (203 KB) |
| Instructions for completing CAP-MR/DD SAR | Word File | |
| CAP-MR/DD Cost Summary | ||
| CAP Rates (revised 03/03/05) | Excel File | |
| Cost Summary Worksheet. This Excel spreadsheet contains macros to connect it to the CAP Rates file. You will need BOTH files: The CAP Rates and the Cost Summary Worksheet. In order to save these files your computer needs to allow macros. | Excel File (209 Kb) | |
| Completing the Cost Summary Manually | Word File | |
| Target Population Forms | ||
| IPRS Target Population Instructions (02/06/04) | Word File | |
| Target Population Definitions: Adult DD FY 2005-2006 |
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| Target Population Definitions: Child DD FY 2005-2006 |
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| Clinical Protocols | ||
| Developmental Disabilities Treatment Protocols | PDF (860 Kb) | |
| Standard Care Guidelines and Levels of Care, Developmental Disabilities (07/01/05) | Word File | |
| Prioritization for Funding through Uniform Portal | ||
| CAP-MR/DD Agency Prioritization List | Word File | |
| CAP-MR/DD Uniform Portal Prioritization Form | Word File | |
| Criteria for CAP-MR/DD | Word File | |
| Uniform Portal Process | Word File | |
| Visual of Process | Word File | |
| Miscellaneous | ||
| TBI Education and Resource Manual | Word File | |
| Utilization Review Tools: UM Tool | Word File | |
| Provider Responsibility for Conducting Utilization Review (09/01/04) | Word File | |
| Important Notice to Case Responsible Agencies (09/01/04) | Word File | |
| Provider Choice Policy (05/20/05) | Word File | |
| Information Collection by Western Highlands Network (06/08/04) | Word File | |
| Western Highlands Service Order Form | Word File | |
| State Funded DD Respite Standard Benefit | Word File | |