Washco Jeopardy

Initials

100

Name two bestview forms you need to complete in your clients folders.

1. Bestview Coversheet
2. Bestview Face sheet

200

What form do you use when you are denying services, reducing services, or terminating services.

(Must have name form number and full form name)

DHS 2828B Notice of action.

300

How many ROI forms does Washington County have?

6

400

What are the two DHS forms you need to send out or provide to clients for Notice of privacy and Notice of rights?

1. 1941
2. 4839E

500

Name all of the WCCS forms.

You can name the last two digits of those forms.

17 - notice of privacy
21 - Electronic Data consent
28 - Consent for the release of information
30 - Consent form to release exchange health info
40 - Informed consent
51 - Notice of rights

DHS forms

100

DHS 2828B

Notice of Action

200

DHS 6790

RMS Worksheet - CRS, employment, DT&H

300

DHS 3427

CADI Screening

400

DHS 3067

DD Screening

500

DHS 6791E
DHS 5181
DHS 3418

DHS MNCH Communication
DHS LTC Communication
DHS MA renewal/MN Care program renewal

CDCS forms

100

What is FMS, SP, and MP

Fiscal Management Services, Support Planner, Managing party

200

DHS 6532

CDCS Community Support Plan

300

For Behavioral exception request renewal. What is needed?

Positive behavioral support plan. 

400

Name four sets of requirements for Exception request

1. Employment/Day support

2. Behavioral
3. Moving to own home
4. Moving from institution

500

DHS 6633
DHS 6633A
DHS 6633B
DHS 6633C
DHS 6633D

DHS 6633 - Budget exception
DHS 6633A - Addendum
DHS 6633B - Enhanced Budget request(PCA complex)
DHS 6633C - Instruction to copmlete exception
DHS 6633D - Shared care

Traditional

100

Name 3 types of IHS

1. IHS w/o Training
2. IHS w/Training
3. IHS w/Fam Training

200

Name at least 4 services that requires to send you a 6790?

Community Residential Services or Family Residential Services 

Customized Living Services

Hour Customized Living Services

Day and Employment Services

Adult day (daily) – S5102

Adult day (15 min) – S5100

Day support services (15 min) – T2021 UC

Employment exploration services (15 min) – T2019 U2

Employment development services (15 min) – T2019 U3

Employment support services, group (15 min) – T2019 HQ

Employment support services, individual (15 min) – T2019 U9

Prevocational services (daily) – T2014 UC

Prevocational services (15 min) – T2047

Transportation, day support services

Integrated community supports 

300

How many months do you authorize HSS

and how many units

6 months

600 units

400

How much can a CM authorize without going to the committee
Homemaker?
IHS?

Homemaker - 10 hours weekly

IHS - 4 hours daily

500

Limit costs of supplies and equipment's 

$3909

Misc

100

Name 3 providers/services who needs to sign 6791D

Employment, CRS, Day program, CL, 

200

How many business days do you have to case note before it is LATE?

3 business days

300

How many days do you have for intial contact

3 days

400

When can you submit a Service agreement

ASAP?

500

Explain DAP format case noting.

D:
A:
P:

description

action

Purpose