Checklist for New OBRA/Independence Waiver Consumers

Annual Reassessment Checklist Independence/OBRA/CommCare Consumer Name: Date of recertification visit: Forms completed during the recertification visit: CMI & CMI Narrative (you may want to complete some of the demographic information before the visit) * Service Provider Choice Form w/Compass list (please print the Service Details page from HCSIS to review the current services and agencies the consumer receives.)* Freedom of Choice Form* Individual Service Plan (Service Plan)* ______Rights and Responsibilities Non-Discriminatory Policy Statement UCP Abuse/Assault list ______Waiver Procedure for Suspected Cases of Abuse, Neglect and Exploitation of Recipients ______UCP Abuse Acknowledgement Notice of Policy Practices (UCP) “Notice of Privacy Practices” Acknowledgement Form Procedure for Consumer Satisfaction Policy on POA, Legal Guardian, and Beneficiary of a Life Insurance Policy Advocacy Packet Consumer Emergency Plan (print last years and review) *Denotes required forms for OLTL Forms completed after visit: IW only (send Certificate of Need to PCP) OBRA only (send Re-Certification of Need to PCP; consumer signs) Complete Notification of Eligibility Send Notification of Eligibility and copies of all forms signed to the consumer Update HCSIS (must be submitted at least 30 days prior to the re-assessment date; SC must submit 5 days prior to 30 day date to allow for supervisory review) Enter visit log note into HCSIS ______SC Reassessment tracking list updated SC Signature:

To be completed by SC Supervisor: Date reviewed HCSIS plan Date reviewed Service Plan Date reviewed CMI Confirmed log note entered into HCSIS Reviewed and confirmed all forms signed during reassessment visit were dated and signed by consumer/representative, SC and completed correctly. ______SC Reassessment tracking list updated Supervisor Signature: R/MG: 8/15/12