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HCBS Authorized Service for Incurment - DOC by vef11fF0

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									                                                                                                                       BSB 899-3
DPHHS-SLTC-131                                              STATE OF MONTANA
      (Revised 6/08)                             Department of Public Health and Human Services
      Page 1 of 2

                                   Home and Community Based Services
                                    Authorized Services for Incurment
       Consumer Name:                                                                               SSN:

       Case Manager Independence Advisor                                                          Phone No.:

       Agency:
       Initial Authorization ___________                                     Change               ___________

                                                Services Used for Incurment
                                                                                                                   Amount applied
                                                            Provider
          Start Date     Service        Provider                                   Units           Cost Per Unit    to monthly
                                                            Number
                                                                                                                     incurment

                                                                                                                   $

                                                                                                                   $


                                                                                                                   $


                                                                                                                   $
       Grand Total Month
                                                                                                                   $
       Time Period
       From (Mo./Yr.):                                                        To (Mo./Yr.):


       Remarks:


                                   Attach bills from providers for each service.

       The grand total above will be used toward the consumer’s incurment. The selected services will not be
       payable by Medicaid during the relevant time period.


       Consumer’s/IA/Case Manager Signatures:                                              Date:____________________________
       ______________________________________________________

                                    Distribution: White-County; Yellow–Case Management Team; Pink-Consumer


       August 1, 2008                            Senior & Long Term Care                                                  Page 2 of 3
                                                                                              BSB 899-3

    DPHHS-SLTC-131
    (Revised 1/06)
    Page 2 of 2


                                           BIG SKY BONANZA SERVICES


Consumer Directed Services:
Community Bundled Support Services
Financial Manager
Goods and Services (Supplies)
Goods and Services (Other than supplies)
Independence Advisor
Private Duty Nursing


Traditional Waiver Services:
                                                      Chemical Dependency Counseling – Individual
Adult Day Health
Chemical Dependency Counseling – Group                Dietician

Environmental Accessibility Adaptations               Habilitation

Nutrition (meals)                                     Occupational Therapy

Physical Therapy                                      Private Duty Nursing

Respiratory Therapy                                   Registered Nurse Supervision

Specialized Medical Equipment & Supplies              Speech Therapy




    August 1, 2008                          Senior & Long Term Care                                 Page 3 of 3

								
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