Notice of Change in BASIS:
For any changes in the Information section or
Services section of the BASIS assessment please fill out this form
and return to the Cottonwood CDDO (This includes any changes in case
management within the same provider)
PDF
Form Version:
Notice of Change
(Fill in blanks & click "submit" to automatically send
to CDDO, or save to computer & email as attachment)
Printable Version:
Notice of Change
(Print this version and fill it out by hand)
How to Fill out the Services Section:
►
Individual Starting a new
Service for the 1st time:
In the appropriate section, type in the “Provider
Name”, Then under “Date Entered”
type the date that the individual will begin receiving services.
►
Individual Changing a
Service from one provider to another:
In the appropriate section, type in the
new “Provider Name” Contact
the CDDO Liaison for all changes
between providers. (TCM, Day or
Residential)
►
Individual Closing out of a Service:
In the appropriate section, under “Date Closed” type in the last day
that the individual will be
receiving services. Then under RCC, type in the Reason Closed Code Number.
(see RCC Codes at the bottom of
the 2nd page of the Notice of Change form)
►
Adding an individual to a
waiting list:
In the appropriate section, under “Date Applied” type in the date
that the individual is being added to
the waiting list. (most likely the date that this form is submitted) Then
under “Date Requested” type in the date
that the individual is able to begin receiving services. (These
dates may be
the same)
Note: Individuals can not have a request
date that is more than 3 years from the current date. Individuals
in high school should have a projected
graduation date (possibly included in the IEP) in order to determine
the “Date Requested”.
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