Innovations Waiver Registry of Unmet Needs

Innovations Waiver Registry of Unmet Needs

NC Innovations Waiver is a Home and Community Based benefit plan to support persons with Intellectual and/or Developmental Disabilities (I/DD) to maximize their potential in their natural community settings as an alternative to institutional settings. At the current time, there is no additional Waiver funding available. This application can be completed in order to be considered for the Registry of Unmet Needs (waitlist) for Innovations Waiver services.

To be considered for the Registry of Unmet Needs for Innovations Waiver Funding the following information must be submitted:

Completed Application for Innovations Waiver Registry of Unmet Needs
Most recent psychological evaluation (must include the following)
Intellectual/Cognitive Testing such as IQ Assessment
Adaptive behavior assessment
Diagnosis
If member is over the age of 18, documentation supporting the diagnosis prior to the age of 18

If it is determined that the individual is not an appropriate referral - because the information provided indicates that the person likely does not meet criteria for participation in the Innovation Waiver - he/she will not be added to the Registry of Unmet Needs. You will receive written notification about the decision.

If you have questions about the application process and/or a paper copy of the application is needed, please call Trillium Health Resources at 1-866-998-2597

Background Information

Member First Name*

Member Last Name*

Date of Birth:*

Social Security Number*

Street Address*

City:*

Zip Code:*

County:*

Telephone Number:*

Phone

Gender:*

Select

Other:*

Primary Language:*

Select

Other:*

Diagnosis*

Intellectual/Developmental Disability or Related Medical Condition.

*A Psychological Evaluation or documentation from a physician is required to support a member's IDD diagnosis.

Does the member has a Legal Guardian?*

Yes

No (Self)

Guardian/Legally Responsible Person:*

Is your mailing address the same as the one listed above?*

Yes

Guardian/Legally Responsible Person Mailing Address:*

City:*

Zip Code:*

Guardian/Legally Responsible Person Telephone Number:*

Phone

Guardian E-Mail Address*

If none, enter N/A

Type of Guardianship*

Please include a copy of guardianship document, if applicable.

Select

Please specify:*

Do you have Medicaid?*

Yes

Medicaid ID:*

Medicaid County:*

Do you have Medicare?*

Yes

Do you have private insurance?*

Yes

Private Insurance Company*

Current Services and Supports

Where do you live?*

Select

Other:*

Do you attend school?*

Yes

Specify School and Grade*

Are you employed?*

Yes

Specify where:*

Other:*

What services are you receiving now?*

For example: personal assistance, respite, Medicaid personal care, CAP DA services, CAP C services, adult day program, supported employment, etc.

Other*

Why Innovations?

What are the unmet needs of the individual? What are the pressing issues for the individual/family that could be addressed with Innovations funding?*

Please specify in detail.

Documentation

Most recent psychological evaluation
Physicians Order/Notes for related medical condition(s)
Guardianship Papers (if applicable)

File Upload

Drag and drop files here or

Attestation

Completed By:*

Date Completed*

Relationship to Applicant*

Select

Other:*

Phone Number:*

E-mail Address:*

If none, enter N/A

Has the legal guardian been notified of and approves of this application submission for the Registry of Unmet Needs for the Innovations Waiver?*

Select

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