Long-Term Services and Supports Case Management Tools

Forms and resources used primarily by Single Entry Point Agencies and Community Centered Boards:

ULTC 100.2 Forms

• Service Plan Signature Page - Updated July 2022
• Unit Converter for Support Planning - July 2022
• ULTC 100.2 Initial Screening and Intake Form - Updated March 2020
• Professional Medical Information Page (PMIP)
• Physician Statement of Life Limiting Illness - Updated September 2020
• Eligibility Assessment
• Pre-Admission Screening and Resident Review Level I form (PASRR)
• Certification Page
• ACF/SLP/TLP PETI Form

Supports Intensity Scale (SIS)

• Support Level Review Request Form - Updated August 2022
  • Desk Guide - Updated August 2022
  • Support Level Review TA Call Meeting Recording - August 16, 2022
  • Support Level Review TA Call Presentation - August 2022
     
  • Presentation - March 31, 2022
  • Webinar Recording - March 31, 2022
  • Panel Schedule - March 2022
  • Level 7 Rate Request Form - March 2022
     

• SIS Reassessment Request Form - Updated June 2022
• Support Level Review Process - Updated August 2021
• SIS and Support Level Disclosure Form - Updated August 2021
• SIS Complaint Process - Updated August 2021
• SIS-A Respondent Guide
• SIS-A Respondent Resources

SIS-A Scoring Conversion Tables - 2017

• Appendix B-Scoring Conversion Table
• Appendix C-1-Scoring Conversion Table
• Appendix C-2-Scoring Conversion Table

Support Level Subgroup Definitions - June 2017

American Association on Intellectual and Developmental Disabilities (AIDD) website

Other Forms

• Telligen Express Review Qualification Attestation Form - March 2022
• Nursing Facility Length of Stay Form - June 2020
• State Supported Living Services (State SLS) Support Plan - March 2020
• Children's Extensive Support (CES) Waiver - Behavioral and Medical Supports Application - February 2020
• NMT Approval Form - November 2019
• Rule Waiver Request Form - September 2019
• Over-Threshold Respite Request Form - September 2019
• Case Management Agency and Eligibility Information Sharing Form - June 2018
• Case Management Agency and Eligibility Information Sharing Form Desk Guide - June 2018
• Long Term Care 803 - 2013
• Long Term Care 803 - Russian - 2013
• Long Term Care 803 - Spanish - 2013

Resources

• Single Entry Point Rates Data & Rates Technical Guide - June 2021
• Community Centered Board Data & Rates Technical Guide - June 2021
• LTSS Training - resource for training materials designed for Long-Term Services and Supports Case Managers
  • HCBS Waiver Charts
  • Transition from Children's to Adult Waivers Checklist
• Long-Term Services and Supports Programs Page
• BUS Stop - resource for updates, forms and projects for the Benefits Utilization System (BUS)
• PASRR - resource for information and forms for Pre-Admission Screening and Resident Review program
• State Long-Term Care Ombudsman Website