Policy and Forms

TBIW Services Manual
Chapter 512 Traumatic Brain Injury Waiver (TBIW) Policy Manual

TBIW Policy Clarifications/Updates
Incident Management System Memo June 30. 2023
Home and Community-Based Services (HCBS) Rates MemoJune 30, 2023
ADW/TBIW Provider Memo
TBIW Rate Increase Memo Effective April 2020
BMS Guidance on Legal Guardians/Medical Power of Attorneys
Guardianship Q&A Follow-Up 
Approved POC Six-Month Follow Up
Disqualifying Findings added to WV CARES
BMS Reconsideration for Personal Attendants at Medical Appointments
CPS Reporting Memo

Approved TBI Waiver Forms

PDF Version FormsForm Instructions/Examples
Microsoft Word/Excel Form Versions
Please note the file may ask for a password
just press Enter.
Do Not Alter Forms
Monthly Case Management Log  Monthly Case Management Log
Case Manager Initial/Annual Training Log Case Manager InitialAnnual Training Log
Case Management Monthly Contact Form Case Management Monthly Contact Form
Conflict of Interest Exception Application  
Environmental Accessibility Adaption (Home/Vehicle)Environmental Accessibility Adaption (Home/Vehicle)Environmental Accessibility Adaption (Home/Vehicle)
Good Day/Bad Day Discovery ToolGood Day/Bad Day Discovery Tool InstructionsGood Day/Bad Day Discovery Tool
Grievance Form Grievance Form
Interim Service Plan Interim Service Plan
Medical Necessity Evaluation Request Form (MNER) Medical Necessity Evaluation Request Form (MNER)
Member-Controlled Settings Assessment
WV Statewide Transition Plan Brochure		Living Arrangements and Setting Assessment Chart

 		Member-Controlled Settings Assessment
Morning Rituals Discovery ToolMorning Rituals Discovery Tool InstructionsMorning Rituals Discovery Tool
Person-Centered Service Plan Addendum Person-Centered Service Plan Addendum
Person-Centered Assessment Person-Centered Assessment
Person-Centered Six-Month Assessment Person-Centered Six-Month Assessment
Person-Centered Assessment Additional Medication List Person-Centered Assessment Additional Medication List
Person-Centered Service Plan Person-Centered Service Plan
Person-Centered Six-Month Service Plan Person-Centered Six-Month Service Plan
Personal Attendant Initial Annual Training Log Personal Attendant Initial Annual Training Log
Personal Attendant Worksheet Personal Attendant Worksheet
 Pest Eradication Requirements 
Provider Agency Change Request Provider Agency Change Request
Request for Discontinuation of Service Request for Discontinuation of Service
Request for Internet-Based TrainingRequest for Internet-Based Training 
Responsibility Agreement Template Responsibility Agreement Template
TBIW Prior Authorization Cover SheetTBIW Prior Authorization Cover Sheet 
Budget Template Personal OptionsBudget ConfigurationsBudget Template Personal Options
Budget Template TraditionalBudget ConfigurationsBudget Template Traditional
Transfer Request Transfer Request
TBIW Information and Monitoring
Abuse Reporting Brochure
Guidance Service Plan and Quality Review
Home Visit Flyer
Self-Audit/Self-Report Form
Standard Repayment Form
Remittance
Provider Review Tool
TBIW Quality Review Process
TBIW Change in Need Guidance Document 2024
TBIW Incident Management System Reporting Chart
TBIW Service Plan Quality Review Self-Monitoring Tool
Personal Attendant Assisting with Occupational Therapy and Physical Therapy
Tip Sheet Personal Attendant Services 2024
Suggested Chart School-Aged TBIW Program 2024