REVISED 10/29/24
Name of Agency:
Date of Review:
Individual's Name:
Sample #:
Type of review: _ CILA _ CDS _ SDA _ CRW _ HBS
| Reason for Change of Status |
Date of Change |
| Transfer to different Agency/Provider(1) |
- |
| Change in Primary Service Type (CILA/HBS/CDS)(1) |
- |
| Death(2) |
- |
| Transfer out of Services |
- |
| Discontinue SDA |
- |
| Name/Demographic Change/Correction |
For name/demographic changes/corrections only: in Comments/Notes section below, note the name/demographic information as it appears on the Waiver Sample, the correct/revised name/demographic information, SSN, date of birth, and ISC/Provider contact information. Submit a copy of this Change of Status form to the Assistant BQM Administrator via email. |
| Additional Information Needed |
- |
| Alternate Needed |
Contact supervisor for alternate individual |
| Address Change of Residence |
New Address: |
| Other |
Description: |
| Name of new Agency/Provider |
- |
| Address of new Agency/Provider |
- |
| Type of Services being Provided at new Agency/Provider |
_ CILA _ CDS _ SDA _ CRW _ ICFDD _ SODC _ HBS |
| (1) For individuals who have transferred to a different provider, changed primary service/program type, transferred out of services, discontinued SDA, or who have died, Reviewer will contact Supervisor to determine if an alternate is needed for review and/or NCI (adult participants only). |
Comments/Notes: |
| (2) In cases of death or cessation of ALL services, Reviewer will save a copy of the STAR form for the individual into the review folder. |
Reviewer: |
For Supervisor Use:
| Follow Up Assigned |
Reviewer Assigned |
Date Assigned |
Notes |
| Desk Audit |
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| Record Assigned to Correct Agency |
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| Alternate Assigned and Scheduled |
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| Other |
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Supervisor:
Date: |
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