DHS-5820-ENG (Disability Waiver Rates System Exception Request)

Consumer Information

RECIPIENT FIRST NAME

LAST NAME

DATE OF BIRTH

PMI

LEAD AGENCY - COUNTY OF RESIDENCE

Relevant diagnosis codes (list only diagnoses related to the exception request)

Diagnosis code

Code description

DATE SUBMITTED TO DHS

REQUESTED START DATE

DATE REQUEST SUBMITTED TO LEAD AGENCY

Explanation for late submission if provider submitted request to lead agency more than 90 days after the requested start date

TYPE OF REQUEST

New

Renewal

Is this service remote?

Yes

FOR THE FOLLOWING SERVICE (one service per form)

STAFFING RATIO (if applicable)

Expedite?

Yes

REASON

OTHER REASON

Summary of Extraordinary Need

(check all that apply)

Physical agression

Verbal agression

Property destruction

Medical fragility

Medical complexity

Transportation – distance

Transportation – behavior

Other

Describe other

Exception Request Information

Wages

REASON

Training

REASON

Leave days

NUMBER OF LEAVE DAYS

Workers comp

REASON

Other

REASON

MnCHOICES CSSP/RATE PLAN NUMBER

RMS FRAMEWORK RATE

REQUESTED RATE

Lead agency determination:

Approves this request

Denies this request

EXPLANATION/REASON FOR DETERMINATION

Provider Information

PROVIDER

NPI

PROVIDER CONTACT NAME

Attach Documentation

Copy of MnCHOICES RMS rate calculation (required)

Upload up to 1 file in PDF, Word, Excel, JPG, PNG, TIF, GIF or text format.

Cost documentation (required)

Upload up to 1 file in PDF, Word, Excel, JPG, PNG, TIF, GIF or text format.

Other supporting documentation as evidence of need

Upload up to 3 files in PDF, Word, Excel, JPG, PNG, TIF, GIF or text format.

Submit

Person submitting request

FIRST NAME

LAST NAME

PHONE NUMBER

EMAIL ADDRESS

Do you want a PDF of the submitted form emailed to the email address above?

Yes

Disability Waiver Rates System Exception Request Application

Consumer Information

Summary of Extraordinary Need

Exception Request Information

Provider Information

Attach Documentation

Submit

Person submitting request

DHS Review