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Thursday - August 28, 2008 - 05:29 pm CST


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    •  

                       Lee County, Iowa

                HCBS Waiver Funding Request

     

    Consumer:

         

    Case Manager:

    Date:

     

    TCM Agency:

     

     

     

    New:

    Change:

    Termination:

     

    Service:

         

    Rate:

    $     

    Per Unit:

         

    Total Units:

         

    Service Period:

         

    To:

         

    Total Cost of Service:

    $     

    Approximate Cost to Lee County (38% of Total Cost):

    $     

    Provider Agency:

         

    City:

         

     

    Brief paragraph explaining service needs.

         

     

     

     

     

     

     

     

    New:

    Change:

    Termination:

     

    Service:

         

    Rate:

    $     

    Per Unit:

         

    Total Units:

         

    Service Period:

         

    To:

         

    Total Cost of Service:

    $     

    Approximate Cost to Lee County (38% of Total Cost):

    $     

    Provider Agency:

         

    City:

         

     

    Brief paragraph explaining service needs.  

         

     

     

     

     

     

     

     

     

    New:

    Change:

    Termination:

     

    Service:

         

    Rate:

    $     

    Per Unit:

         

    Total Units:

         

    Service Period:

         

    To:

         

    Total Cost of Service:

    $     

    Approximate Cost to Lee County (38% of Total Cost):

    $     

    Provider Agency:

         

    City:

         

     

    Brief paragraph explaining service needs.

     

     

     

     

    Submitted By:

     

     

                                                                                                                           

    Targeted Case Manager                                               Date

     

    Approved By:

     

     

                                                                                                                           

    Chairperson, Lee County Board of Supervisors             Date

     

     

     

     

    Lee County CPC | 933 Avenue H | Fort Madison, Iowa 52627 | 319-372-5681 | Information