AIDS Waiver Application

Pennsylvania Home and Community-Based Services 0192 AIDS Waiver Application

PLEASE READ BEFORE COMPLETING APPLICATION

This form is for requesting services covered by Pennsylvania’s home and community-based waiver for an individual who meets the requirements listed on the Choice of Care Agreement, on page 13 of the application.

CAREFULLY READ THE REQUIREMENTS:

Effective July 1, 2003, individuals with inpatient hospital insurance, including Medicare coverage, are now eligible for services through this Program. The following individuals are excluded from this Program:

enrollees of a Health Maintenance Organization (HMO), unless deemed eligible using special income guidelines. Note: These individuals may receive similar services through existing HIO or HMO programs. Please contact your HMO or HIO Special Needs Coordinator.
enrollees of a Medical Assistance Hospice Program.
applicants under the age of twenty-one.

The completion of this form should be coordinated by the applicant’s case manager, hospital discharge planner, or an advocate in cooperation with the applicant, and the attending physician. Coordination with, or the assistance of a home health agency representative is necessary if home health services (nursing visits, home health aide visits, or homemaker services) are requested. SERVICES ON THIS APPLICATION MUST BE PRESCRIBED AND VERIFIED BY THE ATTENDING PHYSICIAN; THEREFORE, AN APPLICANT CANNOT COMPLETE THIS FORM BY HIM/HERSELF.

Items 1 through 19 should be completed as thoroughly as possible for each applicant.
Items 20 through 26 must be completed only if the applicant needs the service.
To establish medical necessity, use item 28 to provide pertinent information.
All applications must contain the required client and physician’s signatures and a completed level of care determination.

Note: If the level of care is not completed, the application will be pended or returned. If a home health agency has completed a HCFA form 485, attach the completed HCFA 485 instead of completing questions 12, 14, 15, 16, 17, and 19.

APPLICATIONS TO THE DEPARTMENT THAT ARE NOT THOROUGHLY COMPLETED WILL BE RETURNED. An incomplete application may delay the processing of the application.

Please send completed application to:

Department of Public Welfare
Department of Aging
Office of Long-Term Living
Bureau of Individual Supports
P.O. Box 2675
555 Walnut Street, 5th Floor
Harrisburg, Pennsylvania 17105-2675

Direct questions in regard to the AIDS Waiver Program, or how to complete the application, please call:

1-800-922-9384,
or locally at 717-787-8091

All information on the application will be kept confidential.

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