MODULE 2: Part A

Preparing for and Beginning Services Facilitation

This module includes information on the steps a services facilitator is responsible for as referrals are received and initial contact is made with the individual and employer of record.

All DMAS  forms listed in the Service Facilitation Modules can be found on the DMAS WebsiteTo learn more, select For Providers on the left side of page. Select Information for Providers, once on this page go to Provider forms and follow the directions.

Module 2: Part A Materials:

  • A Guide for Long-Term Care Services in Virginia
  • DMAS Employer of Record
  • DMAS-7 EPSDT Personal Care Services Functional Status Assessment
  • DMAS-95 addendum Questionnaire To Assess An Applicant's Ability to Independently Manage CD Services
  • DMAS-95B CD Services Management Questionnaire
  • DMAS-96 Medicaid Funded Long-Term Care Service Authorization Form
  • DMAS-97A/B Agency or Consumer Direction Provider Plan of Care
  • DMAS-98 KePRO Community Based Care Request for Services Form
  • DMAS-99 Community –Based Care Recipient Assessment Report
  • DMAS-99 LOC Community-Based Level of Care Review Instrument
  • DMAS-219 Authorization for Release of Information
  • DMAS-225 Medicaid LTC Communication Form
  • DMAS-456 DD Waiver Plan of Care
  • DMAS-458 LOF Summary Sheet
  • DMAS-459 DD Waiver Documentation of Individual Choice Between Institutional Care or HCBS
  • DMAS-459C ID Waiver Documentation of Individual Choice Between Institutional Care or HCBS
  • DMAS-460 ID Virginia HCB Waiver Choice of Providers
  • DMAS-486 Service Agreement between the Individual and the CD Services Facilitator
  • DMAS-489 Individual Selection of CD Services
  • EDCD Waiver Process Flow for Enrollment
  • Level of Functioning (LOF) Survey
  • Sample Form for Emergency Contacts
  • Uniform Authorization to Use and Exchange Information

Please note: 

  • Effective September 1, 2016, the names of two of the Medicaid Waivers referenced in the modules changed.
  • The Intellectual Disability (ID) Waiver is now the Community Living (CL) Waiver.
  • The Individual and Family Developmental Disabilities Support (IFDDS or DD) Waiver is now the Family and Individual Supports (FIS) Waiver.