Fillable Printable County Board Replacement Waiver Capacity Request Form

County Board Replacement Waiver Capacity Request Form

Ohio Department of Developmental Disabilities

Acuity Assessment Instrument (AAI) Override Form:

Administrative Review for the Adult Day Services Array

SUBMIT THIS REQUEST FORM TO: [email protected]

County Name

County Board/ COG Staff Name Making the Request

OMDRDD number (if known):

Enrollee Last Name: Enrollee First Name:

Guardian’s Last Name: First Name:

Group Assignment Information

Assigned AAI Group: Requested AAI Group:

Current Waiver Span: to Dates for New Group: to

Reason for New Group Assignment and Budget Limitation:

Submission of this form via Email implies the following statements are affirmed by the sender:

 The instructions for the AAI override form have been followed.

Responsibility for providing the local waiver matching funds to serve this individual in the new staff

intensity group requested is the obligation of the requesting County Board of DD.

The individual/guardian, service provider(s) listed and the county board of dd agree with the need to

assign the new staff intensity group requested.

The county board superintendent or designee has authorized the assignment of the new staff intensity

ratio resulting from the group assignment requested.

ODODD will notify the individual and county board/COG, via E-mail, of its determination within 10 calendar days following

receipt of a completed request. At that time, the department, in writing, shall provide the individual of his/her due process rights

and responsibilities as set for the in section 5101.35 of the Ohio Revised Code. Notification will be sent to the individual or

his/her legally appointed guardian, using the addresses provided on the front of this form. To request a copy of this form in

Microsoft Word format, please send your request to IDS.Support@dodd.ohio.gov .

ODODD

Adult Day Ser

vices Array Administrative Review Override Form

Revised: October 2011