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NOTICE OF DECISION
NOTICE OF DECISION
FOR LEE
COUNTY
FUNDING MH/MR/DD SERVICES
REQUEST:
Date
__________Consumer’s Name ______________________
Address ___________Social Security Number _____________
Parent/Guardian (If
Applicable) _________________________
Application Completed ___Yes___ No
Services Requested: Day Treatment_______
ICF/MR ________
Supported Employment ________Transportation
___________
SCL _______Sheltered Workshop ______Work
Activity _____
RCF _________RCF/MR __________ Therapy ___________
Case Management _______Psych Evaluation _____________
Psych Test ____________ Other ________________________
Explanation Of
Request:
__________________________________________________
__________________________________________________
Requested
Dates of Approval ____________To ____________
Service Cost $ _____Per:
Day Hour Month
(circle
one)
Payable To
_________________________________________
Funding Requested By ________________________________
LEE COUNTY
C.P.C. OFFICE DECISION:
Date Of
Decision _____________
Action: Approval __________Denial ________Pending ______
Approved ___________ To __________
Cost Approved $________ Per:
Day Hour Month
(Circle One)
Explanation ________________________________________
Consumer responsible for paying for part of the following
service:____________________________________________
Amount $_______ Per
_______
Payable to
_________________________________________
Prohibition
Against Discrimination: This action
was taken
without regard
to race, creed, color, sex, age, religion, national
origin, or political belief. Right to Appeal: If you are
dissatisfied
with any action or failure to act with regard to an
application for MH/MR/DD
services from Lee
County, you,
your
representative, or provider have the right to appeal in
accordance
with the provisions of the Lee County Mental Health
Services
Management Plan. You should be aware,
however, that
any appeal
must be filed within 30 days of the issuance of the
notice of decision concerning that action. Appeal forms and
instructions
may be obtained from the Administrator, Central Point
of Coordination , P.O. Box 190, Fort Madison,
IA 52627.
Lee County Central Point of Coordination Office
P.O. Box 190
Fort Madison, Iowa 52627
C.P.C.
Office Signature______________________ Date_________
Mental Health Services Management
Plan
Questions? : plogsdon@leecounty.org
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SERVICES & INFORMATION