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Fillable Printable Loc Date Change Request Form 1.13

Fillable Printable Loc Date Change Request Form 1.13

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
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