WPCt= kv䤡[4VE7[z'`iR3i0#_|<$ʗMҦCOV-I԰?0xfBU<=%r w`"W`ːb1k :1f(4_43`nٕ;Gհ%r,ƁqC8J;A JƟ,lCoho kI`g"*kTRlXp^]"LJ 23>wj ކ3J]>?؝ 3/VVlo,POKĂ|%7M,FR1?9^.< {rWa7BCAFZ{;Eۃm#xM^Z*M%rO9/VuܑmQ;%LLL`/4@nïwx+Pxh|C:%G' . #b UN+ %y 0: g 0V wv4zo 0VSb^ d mpU0fa 0U 0" 0 0 0 0B 0 0 0I 0 0 0 03 0 0 0( 0 0X 0 0 0u 0% 0 0s 0! 0! 0;" 0" 0w# 05$ 0>$ 01% 0)& 0 ' 0' 0( 0) 0* 0M+ 02, 0Q, 0:M- 0Y- 0_- 0 ?. 0I/ 00 D/2 D+3 0+3 D/15 0`5 06.6 0d6 0:l7 0^7 0<8 1e@8U68U>8U*9 1uC9 729N9f9a9 B5:E7:f9:a;:fO:aQ:~e:e:e:e:e: B<<<<<<<<<<<<<<<<<<<<< B=== B*=============== B<-G=Adobe PDFTT0(9 Z6Times New Roman RegularX($USUS., ] 'USUS.,  _(#X)XXWVHome&CommunityBased**7(#VERSIONMRUWVDRAFTԈ X ServicesWaiverApplication_MR_/DDWaiver#XaX)X#(.3$ !USUS.,  S2:i+00 e  )USUS.,  _)XX (#X STATE :WestVirginia9(#DATE:July1,2005 X Attachment2:Page1  )Reference:DD2AAnnualMedicalEvaluation#)#(.3$ !USUS.,  3|xa2 U3H $AZVerdana TABLE A*+ (_2623  ..*G+G (_25   /%` ` hp x /23  ../%` ` hp x /   *8+8 (_24  ," hp x ,23  ..," hp x ,  *5+5 (_23 ` ) hp x )23  ..) hp x ) ` *2+2 (_22  &hhp x &23  ..&hhp x &  */+/ (_21  #p x #23  ..#p x #  *,+, (_20 h  p x 23  .. p x h *)+) (_19  pp x 23  ..pp x   *&+& (_18   x 23  .. x   *AA (_17  5+ ` hp x 523  Ԁ5+ ` hp x 5  *GG (_16   /%` ` hp x /23  Ԁ/%` ` hp x /   *88 (_15  ," hp x ,23  Ԁ," hp x ,  *55 (_14 ` ) hp x )23  Ԁ) hp x ) ` *22 (_13  &hhp x &23  Ԁ&hhp x &  *// (_12  #p x #23  Ԁ#p x #  *,, (_11 h  p x 23  Ԁ p x h *)) (_10  pp x 23  Ԁpp x   (&& &_9   x 23  Ԁ x   (AA &_8  5+ ` hp x 523  5+ ` hp x 5  (GG &_7   /%` ` hp x /23  /%` ` hp x /   (88 &_6  ," hp x ,23  ," hp x ,  (55 &_5 ` ) hp x )23  ) hp x ) ` (22 &_4  &hhp x &23  &hhp x &  (// &_3  #p x #23  #p x #  (,, &_2 h  p x 23   p x h ()) &_1  pp x 23  pp x   &&& $_   x 23   x   0AA.Normal  5+ ` hp x 55+ ` hp x 5  <AA:Definition T  5+ ` hp x 55+ ` hp x 5  <AA:Definition L , 5+ ` hp x 5  5+ ` hp x 586Definition(hh&H1  5+ ` hp x 5      5+ ` hp x 5  (]]&H2  5+ ` hp x 5  5+ ` hp x 5  (]]&H3  5+ ` hp x 5  5+ ` hp x 5  (]]&H4  5+ ` hp x 5 XXX 5+ ` hp x 5  (]]&H5  5+ ` hp x 5  5+ ` hp x 5  (]]&H6  5+ ` hp x 5  5+ ` hp x 5  2DD0Address  5+ ` hp x 55+ ` hp x 5  8MM6Blockquote , , 5+ ` hp x 5   5+ ` hp x 5,*CITE,dl*CODEKL<6X9`(Courier NewKSM\  `&Times New RomanS42Emphasis64Hyperlink    <:FollowedHype    4go2Keyboard KL<6X9`(Courier NewKSM\  `&Times New RomanS <:Preformatted  /%  ,Kk %#/KL<6X9`(Courier NewKSM\  `&Times New RomanS/%  ,Kk %#/  <:zBottom of 7A(X7    5+ ` hp x 5?N%2A`Arial?  SM\  `&Times New RomanS7B(X75+ ` hp x 5  w)1dxd'dxd<:zTop of For7D(X7    5+ ` hp x 5?N%2A`Arial?  SM\  `&Times New RomanS7B(X75+ ` hp x 5  w)2dxd0KS.SampleKL<6X9`(Courier NewKSM\  `&Times New RomanS0.Strong 8dl6TypewriterKL<6X9`(Courier NewKSM\  `&Times New RomanS42Variable: 8HTML MarkupB      2 0CommentB   !" 35;AGMSY_11.1.1.1.1.1.1.1.<6X9`(Courier New\  `&Times New Roman%2A`Arial3#37=CIQYag1.a.i.(1)(a)(i)1)a)Oi)TABLE B1Large Dashed dTABLE CTABLE DDD-2A (proposed)   ' MRU WV0Debi .    d d&0 d d)Hairline d !USUS.,  _XX   __xX}5XXXsXX}5WESTVIRGINIADEPARTMENTOFHEALTHANDHUMANRESOURCES R ANNUALMEDICALEVALUATION  s  *ddd Xdd Xdd X(#(#, , , , +  /% /ParticipantName: =,! = 6,!" 6Date: .3 . G='"   GParticipantAddress: =,!y = 6,!y" 6_Birthdate_: .y 3 . G='y "   G =,!J  = 6,!J " 6SS#: .J 3 . G='J"   G =,!m = 6,!m" 6Medicaid#: .m3 . G='m"   GParticipanteMail: =,!>  = 6,!> " 6Phone: .> 3 . PF'> "   <P OE/ " <  OBehavioralHealthCenter: =,!K  = 6,!K " 6 'K 3 ' 8.K   8_BHC_ԀAddress: =,!  = 6,! " 6Phone: . 3 . G=' "   G =,!   = 6,! !" 6Fax: . "3 . PF' #"   <P OE/ T$" <  OPhysician: =,! % = 6,! &" 6 ' '3 ' 8. (  8PhysicianAddress: =,! y ) = 6,! y *" 6Phone: . y +3 . G=' y ,"   G =,!J - = 6,!J ." 6Fax: .J /3 .7-+J 0"   7*XYd d    (#(#_,X , ,P +  0& 1   0DIAGNOSES 6% 2    6  :0! 3  :ЀMENTAL:Listallcognitive,developmental,behavioral,emotionaland/orpsychiatricconditions. ;1 4    ;  A0!F 5  A   `    J@*F 6    J  A0!] 7  A   `    E4*] 8    E  :0!"9  :ЀPHYSICAL:Listallchronicandhandicappingconditions,aswellascurrentacuteconditions. ;1":    ;  A0!;  A   `    J@*<    J  A0!Z=  A   `    PF*Z>   <P  A7 Y?  <   AMEDICALNEEDS(_Rx_Ԁwithamounts;validfor1yearunlessotherwisenoted.) D3[@    D 6,!r A" 6ЀNURSINGCARE(specify) .r B . QG,r C     Q 6,!7D" 6 .7E . UD,7F     U 6,!G" 6ЀPERSONALCARE/HYGIENE .H . UD,I     U 6,!oJ" 6ЀTHERAPY: .oK . UD,oL     U 6,!4M" 6ЀSPEECH .4N3 . UD,4O     U 6,!KP" 6ЀPHYSICAL .KQ3 . UD,KR     U 6,!S" 6ЀOCCUPATIONAL .T3 . P?,U     P 6,!V" 6OTHER(specify) .W3 . K:'X    K 6,!HY" 6ЀEQUIPMENT/SUPPLIES: .HZ . K:'H[    K 6,!_ \" 6MOBILITY ._ ]3 . K:'_ ^    K 6,!$_" 6CONTINENCE .$`3 . K:'$a    K 6,!b" 6FEEDING/NUTRITION .c3 . K:'d    K 6,!\e" 6OTHER(specify) .\f3 . P?'\g    P 6,!s !h" 6ЀOTHER(specify) .s !i . QG,s !j     Q 6,!8!k" 6 .8!l .<208!m     <  sIcertifythatthispatientsdevelopmentaldisabilityandrelatedhealthneedsareasdocumented "4n above,andthepatient,butfortheprovisionofhomeandcommunitybasedwaiverservices, N#o wouldrequirethelevelofcareprovidedinanintermediatecarefacilityforthementally $p retarded*(_ICF_/_MR_).#s!# $ q *RSddX X P PXY(#(#, , , +  8'G&!sG&! 8 =,!G&!t" = =,!G&!u" = ND,G&!v"   NDate '&"w" 'PhysiciansSignature '&"x" 'License#-#!&"y"   -,,*AnICF/MR meansaninstitution(ordistinctpartofaninstitution)that!(1)Isprimarilyforthediagnosis,treatment,orrehabilitationofthementallyretarded *(#z orpersonswithrelatedconditions;and(2)Provides,inaprotectedresidentialsetting,ongoingevaluation,planning,24-hoursupervision,coordination,and (Q${ integrationofhealthorrehabilitativeservicestohelpeachindividualfunctionathisgreatestability.(42CFR435.1009)#,,Ǩ%# )$| A_U) xdE5*xA 6*%~   FORDEPARTMENTOFHEALTHANDHUMANRESOURCESUSEONLY  E*% N(*VWdd   RS(#(#,p ,,#,X ,,#,X +  (*&*& (Formcompleted,withallnecessaryinformationprovided.  *& _ _  *& ЀYes *& _ _  *& ЀNo 6,*&   6Medicaleligibilityestablished.  +}' _ _  +}' ЀYes +}' _ _  +}' ЀNo =,+}'   =   @  @`  @  @ 8'!,N(  8  H>/,N(#    H  NameofReviewer "Y-)  "  Date0&$Y-)#    0