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Name – Participant/ Name – Agency / County
DEPARTMENT OF HEALTH SERVICES
Division of Medicaid Services
F-21353 (03/2017) / STATE OF WISCONSIN
community options program (cop) exceptional expense request
Completion of this form is voluntary. COP agencies should complete this form when requesting COP Exceptional Expense (EE) funding. COMPLETE ALL SECTIONS. Incomplete request forms cannot be reviewed. Project bids, estimates, designs/diagrams or invoices for items/devices requested must be included.
Name – Participant / Date of Birth / Date of Request
Living Arrangement / Bids / Diagrams / Invoice Attached
Own home/apartment / Home of another / Adult family home
Community-based residential facility / Residential care apartment complex / Yes No
Other, specify –
Current Funding Source
COP / COP-W / CIP II / CIP 1A / CIP 1B / Tribal Funds / FC Transfer
Special Funding
CRI / MFP / Diversion / ICF-IDD Relocation / Other, specify –
Name – Care Manager / Service Coordinator / Name – Agency / County / Email Address
I. Briefly describe the person’s current health status and the services currently in place to address his/her needs (diagnoses, condition, limitations; hours/week Supportive Home Care, Medical Assistance Personal Care, Personal Emergency Response System, Home-Delivered Meals, and Transportation):
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Name – Participant/ Name – Agency / County
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II. Describe item/device, service or modification needed. Describe health condition or safety concern this will address.
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Name – Participant/ Name – Agency / County
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III. Has the item, device, or modification been recommended by a physician, occupational therapist, physical therapist, or independent living center?
Yes – specify below No – requested by whom?
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Name – Participant/ Name – Agency / County
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IV. Describe efforts to obtain coverage from Medicaid, Medicare, or another funding source.
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Name – Participant/ Name – Agency / County
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V. Total Amount Request:
Has this person received COP EE funding in the past? No Yes
If yes, date funding approved: and amount: . What was purchased and why?
VI. If required, has this request received prior approval (Area Quality Specialist, The Management Group)?
Approval Pending – Date: Approval Received – Date:
DHS FUNDING DECISION
Approved – Date: Denied – Date: Hold for More Information – Date:
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