B: Aged and Disabled Medicaid Waiver Plan of Services and Supports Nebraska Department of Health and Human Services (DSS-12AD)
Appendix B
DSS-12AD
Client's Name
Social Security Number
Page
______ of ______.
Services Coordinator
Date
SECTION 1: OUTCOMES
Assessment Section:
Desired Outcome:
SECTION 2: ACTION STEPS
Steps to be Taken
By Whom
Date
Progress
SIGNATURES (Optional)
Services Coordinator
Client
Other
DSS-12AD Rev. 6/98 (27004)
(Previous version 3/96 should be used first)
B