DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-00076 (06/2009)
STATE OF WISCONSIN
VARIANCE REQUEST WAIT LIST
A variance request is required in order to receive an exception to the Medicaid Home and Community-Based Waiver wait list policy. Use of this form is optional.
Name Applicant Potential Funding Source (Check one) COP W CIP II BIW Name - Agency and Care Manager / Support and Service Coordinator Detail reason applicant should receive variance to statewide waitlist policy:
Date of Request
CIP IA CIP IB
CLTS DD CLTS PD CLTS SED
Submit variance request to: · COP-W / CIP II Kimberly Schindler (BLTS) · CIP 1A / 1B Community Integration Specialist (CIS) · CLTS Children's Services Specialist (CSS) Approved Denied SIGNATURE Authorized BLTS Representative Date Approved/Denied