Fillable Printable Loc Date Change Request Form 1.13

Loc Date Change Request Form 1.13

Ohio Department of Developmental Disabilities

LOC DATE CHANGE REQUEST FORM

DODD LOC Date Change Request Form 0113

First Name:

Last Name:

County:

DODD #:

Current LOC Date New LOC Date

The new LOC start date must be prior to the end date of the current LOC

Start Date:

End Date:

Start Date:

End Date:

EXAMPLE

LOC Dates:

Current LOC 7/1/12 to 6/30/13

New LOC 9/15/12 to 9/14/13

Required PAWS:

7/1/12 to 9/14/12 – Revision

9/15/12 to 9/14/13 - Redet

Reason for LOC Date Change Request

Moving into a new setting and aligning span dates with roommates

SELF waiver classification change:

Child to adult (effective date will match new LOC date indicated on this form).

Other: Reason indicated:_____________________________

LOC Date Change Checklist

Submit this form to [email protected]

Freedom of Choice Form to be completed and kept on file at the county board.

Submit to Medicaid Payment & Support (Fiscal/PAWS)

A revision PAWS that end dates the current LOC waiver year

A redet PAWS that reflects the NEW LOC dates if applicable

Prior Authorization

Changes to the LOC span dates may affect a Prior Authorization request previously submitted to the

Department. A new Prior Authorization

Completed by: Email: Date:

Current Waiver: ☐Lv1 ☐IO ☐SELF