Appendix 9998. FORMS (12VAC30-120)

Virginia Uniform Assessment Instrument (UAI) (1994)

Consent to Exchange Information, DMAS-20 (rev. 4/03)

Provider Aide Record (Personal/Respite Care), DMAS-90 (rev. 6/12)

LPN Skilled Respite Record, DMAS-90A (eff. 7/05)

Personal Assistant/Companion Timesheet, DMAS-91 (rev. 8/03)

Questionnaire to Assess an Applicant's Ability to Independently Manage Consumer-Directed Services, DMAS-95 Addendum (rev. 8/05)

Medicaid Funded Long-Term Care Service Authorization Form, DMAS-96 (rev. 8/12)

Individual Choice - Institutional Care or Waiver Services Form, DMAS-97 (rev. 8/12)

Agency or Consumer Direction Provider Plan of Care, DMAS-97A/B (rev. 3/10)

Community-Based Care Recipient Assessment Report, DMAS-99 (rev. 9/09)

Community-Based Care Level of Care Review Instrument, DMAS-99LOC (undated)

Medicaid LTC Communication Form, DMAS-225 (rev.10/11)

Technology Assisted Waiver Provider RN Initial Home Assessment, DMAS-116 (11/10)

Technology Assisted Waiver/EPSDT Nursing Services Provider Skills Checklist for Individuals Caring for Tracheostomized and/or Ventilator Assisted Children and Adults, DMAS-259

Home Health Certification and Plan of Care, CMS-485 (rev. 2/94)

IFDDS Waiver Level of Care Eligibility Form (eff. 5/07)

Request for Screening for Individual and Family Developmental Disabilities Support Waiver (DD Waiver), DMAS 305 (rev. 3/09)

DD Medicaid Waiver - Level of Functioning Survey Summary Sheet, DMAS-458 (undated)

Technology Assisted Waiver Adult Aide Plan of Care, DMAS 97 T (rev. 6/08)

Technology Assisted Waiver Supervisory Monthly Summary, DMAS 103 (rev. 4/08)

Technology Assisted Waiver Adult Referral, DMAS 108 (rev. 3/10)

Technology Assisted Waiver Pediatric Referral, DMAS 109 (rev. 3/10)