Out-of-CMA Unmet Needs Requests

Out-of-CMA Unmet Needs Requests

Please complete the following information regarding the individual and service need. We will reach out to you for additional information needed such as Letter of Recommendation, Medicaid or Insurance denials, invoices, and payee information. Please add Developmental Pathways to the BUS so that we can gather additional information about the individual and request.

Please note that all individuals requesting Unmet Needs Funding must complete Release of Information and Privacy Policy. The website for these forms are (copy and paste into web browser):

Release of Information: https://www.dpcolo.org/wp-content/uploads/2022/04/Authorization-for-Release-and-Exchange-of-Information-2022.pdf

Date of Request*

Case Manager's Name from other Case Management Agency*

Case Manager's Email and Phone Number*

Individual's Name*

Individual's Date of Birth*

CCMS ID*

Individual's County of Residence*

Select

Individual's Waiver*

Does the individual have an IDD determination *

Yes

What is the date of the IDD Determination?*

Dates of Service*

Amount of funding requested*

Service Category*

Briefly describe the need for this request*

What are the needs related to the disability, why is this service needed, and how will it help the individual?

Is this an emergency or urgent request?*

Yes

Is this a one-time request or ongoing request*

One-time Request

Ongoing Request

Provider Information*

Who is the intended provider and will the request be paying the provider directly or reimbursing the individual/family?

File Upload

Please attach any Invoices, Receipts, Letters of Recommendation, Privacy Policy, and Release of Information

Drag and drop files here or

Send me a copy of my responses

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