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
RCF _________RCF/MR __________ ICF/MR _____________
Case Management _________________ Other _____________ Explanation Of Request:
__________________________________________________
__________________________________________________
Service Cost $ _____Per:
Day Hour Month (circle
one) Payable To
_________________________________________
Funding Requested By ________________________________
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:____________________________________________ 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
Signature______________________ Date_________
Mental Health
Services Management Plan
Questions? : plogsdon@leecounty.org
Thursday - January 08, 2009 - 04:02 pm CST
SERVICES & INFORMATION
CPC
TABLE OF CONTENTS
Services Requested: HCBS__________
Day Treatment_______
Supported Employment ________Transportation
___________
SCL _______Sheltered Workshop ______Work
Activity _____
Requested Dates of Approval
____________To ____________
Amount $_______ Per _______
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