Provider Choice / Change Form

Provider Choice / Change Form

*Complete form when choosing a new provider or changing existing provider(s).
Name of person receiving services*

First NameLast Name
Date of Birth*

MonthDayYear
Name*
(Name of the person receiving services)
Email*
example@example.com
I understand the provider may not be available at the time this choice form is received at the CDDO.
Assistive Services
Provider Type:

New ServiceChange Provider
Targeted Case Management
Targeted Case Management: Check provider availability
Providers:
Type:

New ServiceChange Provider
Day Supports
Day Supports: Check provider availability
Providers:
Type:

New ServiceChange ProviderAdd Additional Provider
Supported Employment
Supported Employment: Check provider availability
Providers:
Type:

New ServiceChange Provider
Residential Supports Adults: Check provider availability
Providers:
Type:

New ServiceChange Provider
Residential Supports
Residential Supports Children
Provider Type:

New ServiceChange Provider
Personal Care Service
Personal Care Services: Check provider availability
Providers:
Type:

New ServiceChange Provider
Supportive Home Care
Supportive Home Care: Check provider availability
Providers:
Type:

New ServiceChange Provider
Medical Alert: Check provider availability
Providers:
Type:

New ServiceChange Provider
Specialized Medical Care
Specialized Medical Care: Check provider availability
Providers:
Type:

New ServiceChange Provider
Independent Living Counseling
Provider Type:

New ServiceChange Provider
Enhanced Care Service
Enhanced Care Service: Check provider availability
Providers:
Type:

New ServiceChange Provider
Overnight Respite: Check provider availability
Providers:
Type:

New ServiceChange Provider
Overnight Respite
Wellness Monitoring
Wellness Monitoring: Check provider availability
Providers:
Type:

New ServiceChange Provider
By signing I give the Johnson County CDDO permission to share my information with my requested provider.
Signature of Person Served

Clear
Please sign with your finger, stylus, or mouse
Date

MonthDayYear
**Signature of Legal Guardian

Clear
Please sign with your finger, stylus, or mouse
Date

MonthDayYear
Please complete the following section if this form has been signed by a Legal Guardian.
Guardian Name

First NameLast Name
Guardian Phone Number
Please enter a valid phone number.
Guardian Email
example@example.com
Provider Referral Form
The CDDO has confirmed your agency is open for referrals on our website. The above named person has chosen you as their service provider.

According to the CDDO/KDADS Contract and the Affiliate Agreement, when funds are available and the CSP is selected, services will be provided to the person within an average of 60 calendar days from the date this referral is accepted. Crisis referrals may require less time.

If you are not planning to serve the person within 60 calendar days, please provide a detailed explanation.

Explanation:

The services marked below indicate the service requested from your agency. Please indicate the date services are expected to start and the staff you want assigned in Welligent.
Assigned Staff:

First NameLast Name
Service Provider Signature:*
Please enter your full name as legal signature
Date:

MonthDayYear
Should be Empty:

Provider Choice / Change Form

Provider Referral Form