Long-Term Services and Supports Case Management Forms and Tools

Forms and resources used primarily by Case Management Agencies (CMA):

Case Management Agency Forms (Offline)

• Care Plan Form - July 2023
  
• LTC Assessments for IADLs Form - July 2023
  
• Service Plan Form - July 2023
  
• Assessment/Support Plans: LTC Level of Care Eligibility Assessment (Legacy ULTC 100.2) - June 2023
  • This form replaces the ULTC 100.2 Initial Screening and Intake Form
    
  • This form replaces the ULTC 100.2 Initial Screening and Intake Form
    
  • This form replaces the Case Management Agency and Eligibility Information Sharing Form - 2018 and June 2023
    
  • This form replaces the Certification Page
    
  • No changes to this form - continue to use this form per regulatory and contractual requirements.
    
  • No changes to this form - continue to use this form per regulatory and contractual requirements.

  Care and Case Management System (CCM) Resources

  • CCM FAQ
  • CCM Known Issues
  • CCM Roadmap to Success
  • Care and Case Management System Page
  • Care and Case Management Home Page

  Critical Incident Report Forms (Offline)

  • Critical Incident Form - Criminal Activity - June 2023
  • Critical Incident Form - Damage to Consumer's Property or Theft - June 2023
  • Critical Incident Form - Death - June 2023
  • Critical Incident Form - Injury or Illness to Client - June 2023
  • Critical Incident Form - Medication Management - June 2023
  • Critical Incident Form - Missing Person - June 2023
  • Critical Incident Form - Mistreatment, Abuse, Neglect, Exploitation - June 2023
  • Critical Incident Form - Unsafe Housing - June 2023
  • Critical Incident Form - Other High-Risk Issues - June 2023

  Developmental Disability Determination Forms and Resources

  • Developmental Disability and Delay Determinations FAQ - April 2020
    
  • Request for Developmental Disability Determination Form - Updated July 2019
    • Spanish Version - May 2019
      
    • Spanish Version - April 2019
      
    • Spanish Version - April 2019
      
    • Developmental Disability and Delay Determinations FAQ Sheet - September 2019
      
    • FAQ - The Role of Psychological Testing in Accessing Medicaid Services - December 2018
      

    Notice of Action (803) Forms

    • Long-Term Care Application Status Letter - April 3, 2024
    • Long-Term Care Benefits Status Letter - April 3, 2024
    • Long-Term Care Developmental Disabilities (DD) Waiver Waitlist Letter - April 3, 2024

    Program and Waiver-Specific Resources

    • Rights Modification Documentation Form - June 2023
      • Informed Consent Template - March 2021

      Supports Intensity Scale (SIS)

      • Risk Factor Training - May 2024
        
      • Support Level Review Request Form - Updated May 2023
        • Level 7 Rate Request Form - March 2022
        • Desk Guide - August 2022
        • Support Level Review Process - August 2021
          • Support Level Review Process - Spanish
          • SIS Assessment Report Cover Letter - Spanish
            
          • SIS and Support Level Information and Disclosure - Spanish
            
          • SIS Complaint Process - Spanish

          SIS and Support Level Review Technical Assistance Meetings

          • May 17, 2023
            • Presentation
            • Webinar Recording
              
            • Presentation
            • Webinar Recording
              
            • Presentation
            • Webinar Recording
              
            • SIS-A Respondent Guide Spanish - Updated April 2023 (This document was provided by a third party. People using assistive technology may not be able to fully access the information in this file. For assistance, email Mariah.Kohlruss-Ecker@state.co.us)

            SIS-A Scoring Conversion Tables - 2017

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

            Other Forms and Resources

            • LTSS Member Preference Guide - August 2024
            • Telligen Express Review Qualification Attestation Form - March 2022
            • State Supported Living Services (State SLS) Support Plan - March 2020
              
            • 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