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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
‹ A: Service Provider Agreement DHHS (DSS-9)upC: DHHS Assisted-Living Service Provider Addendum, HCB Waiver for Aged Persons, Adults or Children with Disabilities (MILTC-1AD) ›
Posted January 25th, 2008

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