Case Management Services Request Form - Sedgwick County ...
Case Management Services Request Form - Sedgwick County ...
Case Management Services Request Form - Sedgwick County ...
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<strong>Case</strong> <strong>Management</strong><br />
<strong>Services</strong><br />
<strong>Request</strong> <strong>Form</strong><br />
Name:<br />
___________________________________<br />
Date of Birth:<br />
___________________________________<br />
Social Security Number:<br />
___________________________________<br />
Do you currently have a case<br />
manager through any other<br />
provider other than those listed in<br />
this brochure<br />
Yes<br />
No<br />
If yes, please list case manager<br />
name and agency:<br />
___________________________________<br />
_________________________________<br />
Service Providers for individuals<br />
with Medicaid.<br />
Check the service provider you<br />
have chosen to provide <strong>Case</strong><br />
<strong>Management</strong> <strong>Services</strong> (please<br />
only check one):<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
The Arc of <strong>Sedgwick</strong> <strong>County</strong><br />
serves ages 14 & up<br />
Arrowhead West<br />
serves ages 18 & up<br />
Cerebral Palsy Research<br />
Foundation<br />
serves ages 14 & up<br />
Dream Catchers<br />
serves all ages<br />
Goodwill Industries<br />
serves ages 18 & up<br />
Individual Advocacy<br />
serves all ages<br />
KETCH, Inc.<br />
serves ages 18 & up<br />
New Hope<br />
serves all ages<br />
Rainbows United<br />
serves 17 & under<br />
Res-Care Life Choices<br />
serves all ages<br />
Starkey<br />
serves all ages<br />
House of Hope<br />
Serves ages 18 & up<br />
No Preference<br />
If you choose this option you will<br />
be assigned to a service provider<br />
on a rotational basis.<br />
I do not wish to receive <strong>Case</strong><br />
<strong>Management</strong> <strong>Services</strong> at this time<br />
By signing below, I acknowledge<br />
the Service Access and Outreach<br />
Department of the <strong>Sedgwick</strong><br />
<strong>County</strong> Developmental Disability<br />
Organization has impartially<br />
informed me of the types of<br />
community services, including<br />
case management, provided in<br />
<strong>Sedgwick</strong> <strong>County</strong>.<br />
_________________________________<br />
Signature of Individual<br />
_________________________________<br />
Signature of Guardian<br />
_________________________________<br />
Date<br />
For questions please contact:<br />
<strong>Sedgwick</strong> <strong>County</strong> Developmental<br />
Disability Organization<br />
Service Access and Outreach<br />
Department<br />
615 N. Main, Wichita, KS 67203<br />
316-660-7640
Private Payment Options<br />
For individuals without Medicaid:<br />
All of the below agencies accept<br />
private payment for individuals<br />
that do not have Medicaid<br />
coverage.<br />
The cost is $43.32/hour paid on a<br />
monthly basis unless otherwise<br />
advised by the service provider<br />
(please only check one):<br />
<br />
<br />
<br />
<br />
Cerebral Palsy Research<br />
Foundation<br />
serves ages 14 & up<br />
Res-Care Life Choices<br />
serves all ages<br />
KETCH<br />
serves ages 18 & up<br />
Starkey<br />
serves all ages<br />
By signing below, I acknowledge<br />
the Service Access and Outreach<br />
Department of the <strong>Sedgwick</strong><br />
<strong>County</strong> Developmental Disability<br />
Organization has impartially<br />
informed me of the types of<br />
community services, including<br />
case management, provided in<br />
<strong>Sedgwick</strong> <strong>County</strong>. I understand<br />
that I must private pay for case<br />
management services according<br />
to the private pay agreement of<br />
the case management agency<br />
chosen above.<br />
_________________________________<br />
Signature of Individual<br />
_________________________________<br />
Signature of Guardian<br />
<strong>Sedgwick</strong> <strong>County</strong><br />
Developmental Disability Organization<br />
615 N. Main<br />
Wichita, KS 67203<br />
<strong>Sedgwick</strong><br />
<strong>County</strong><br />
Developmental<br />
Disability<br />
Organization<br />
<strong>Case</strong><br />
<strong>Management</strong><br />
<strong>Services</strong><br />
<strong>Request</strong> <strong>Form</strong>
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