CDDO Crisis Request

Person's Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
TCM Name:*
TCM Email:*
example@example.com
Date of Request:*

MonthDayYear
Type of Request:*
Signed current Person Centered Support Plan (PCSP) demonstrating need. If the person requesting services does not currently have a PCSP one shall be completed within 30 days of approval for waiver access:

Minimum requirements necessary before a request can be reviewed by the Crisis/Exception Review Comm.
Cancelof
Current functional assessment within past 12 months:

Minimum requirements necessary before a request can be reviewed by the Crisis/Exception Review Comm.
Cancelof
MCO statement of resources exhausted required:

Cancelof
• UHC: uhcksltss@uhc.com
• Sunflower: KSLifeShare@sunflowerhealthplan.com
• Healthy Blue: institutionaltransitions@healthybluekansas.com
Signed current Behavior Support Plan (BSP) if applicable:

Cancelof
Law Enforcement documentation/Police reports if applicable:

Cancelof
DCF/ANE documentation if applicable:

Cancelof
Signed Individualized Education Plan (IEP) if applicable:

Cancelof
Other pertinent documentation (if applicable) including, but not limited to: Physician recommendations, hospitalization reports, family member/neighbor statements, etc.:

Cancelof
List Natural Supports Exhausted, Including Private Pay Options.
List Service(s) Being Requested.
List MCO Value Added Benefits Exhausted.
List Community Supports Exhausted.
Explain in Detail How Crisis/Exception Funding Will Alleviate Current Situation:
Individual Signature*

Clear
Do you have a guardian?*
Guardian Signature

Clear
Date

MonthDayYear
Should be Empty: