Administrative Code

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Virginia Administrative Code
Title 12. Health
Agency 30. Department of Medical Assistance Services
Chapter 120. Waivered Services
1/21/2020

Forms (12VAC30-120)

Virginia Uniform Assessment Instrument (UAI) (1994)

Consent to Exchange Information, DMAS-20 (rev. 4/2003)

Provider Aide Record (Personal/Respite Care), DMAS-90 (rev. 6/2012)

LPN Skilled Respite Record, DMAS-90A (eff. 7/2005)

Personal Assistant/Companion Timesheet, DMAS-91 (rev. 8/2003)

Questionnaire to Assess an Applicant's Ability to Independently Manage Consumer-Directed Services, DMAS-95 Addendum (rev. 8/2005)

Medicaid Funded Long-Term Care Service Authorization Form, DMAS-96 (rev. 8/2012)

Individual Choice - Institutional Care or Waiver Services Form, DMAS-97 (rev. 8/2012)

Agency or Consumer Direction Provider Plan of Care, DMAS-97A/B (rev. 3/2010)

Community-Based Care Recipient Assessment Report, DMAS-99 (rev. 9/2009)

Community-Based Care Level of Care Review Instrument, DMAS-99LOC (undated)

Medicaid LTC Communication Form, DMAS-225 (rev.10/2011)

Technology Assisted Waiver Provider RN Initial Home Assessment, DMAS-116 (11/2010)

Technology Assisted Waiver/EPSDT Nursing Services Provider Skills Checklist for Individuals Caring for Tracheostomized and/or Ventilator Assisted Children and Adults, DMAS-259 (undated)

Home Health Certification and Plan of Care, CMS-485 (rev. 2/1994)

IFDDS Waiver Level of Care Eligibility Form (eff. 5/2007)

Request for Screening for Individual and Family Developmental Disabilities Support Waiver (DD Waiver), DMAS 305 (rev. 3/2009)

DD Medicaid Waiver - Level of Functioning Survey Summary Sheet, DMAS-458 (undated)

Technology Assisted Waiver Adult Aide Plan of Care, DMAS 97 T (rev. 6/2008)

Technology Assisted Waiver Supervisory Monthly Summary, DMAS 103 (rev. 4/2008)

Technology Assisted Waiver Adult Referral, DMAS-108 (rev. 1/2017)

Technology Assisted Waiver Pediatric Referral, DMAS-109 (rev. 1/2017)

Website addresses provided in the Virginia Administrative Code to documents incorporated by reference are for the reader's convenience only, may not necessarily be active or current, and should not be relied upon. To ensure the information incorporated by reference is accurate, the reader is encouraged to use the source document described in the regulation.

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