Form 3849-A, Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications

Effective Date
03/2012
Document
Document
3849-A.pdf (206.4 KB)

Instructions

Updated: 3/2012

Purpose

To document the specifications for the procurement process.

Procedure

When to Prepare

The Direct Service Agency (DSA) must complete this form prior to procuring bids for adaptive aids or medical supplies costing $500 or more or minor home modifications regardless of the estimated cost.

Transmittal

The DSA retains a signed/dated Form 3849-A in the individual's record. A copy is provided to the case manager and the individual/legally authorized representative (LAR) within seven calendar days of completion of the form.

Form Retention

The case manager and DSA retain Form 3849-A according to the terms of the Community Living Assistance and Support Services (CLASS) Provider Manual.

Detailed Instructions

Section I

Individual's Name — The DSA enters the individual's name as it appears on page 1 of Form 3621, Individual Plan of Care (IPC).

Medicaid No. — Enter the Medicaid number of the CLASS individual.

Individual's Address — The DSA enters the individual's address.

Physical Address of Location to be Modified — The DSA enters the physical address of the location to be modified, in the event that the individual's address and actual location to be modified differ.

If the above addresses are not identical, explain — In the event that the individual's address and actual location to be modified differ, the DSA must document the reason.

Adaptive Aids/Medical Supplies/Minor Home Modifications Requested — The DSA enters the adaptive aids/medical supplies/minor home modifications as they appear on Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation.

Specifications for Item/Service to be Purchased — The person writing the specifications lists the specifications or attaches the specifications, citing any applicable local regulations, requirements of the construction and applicable Texas Accessibility Standards (TAS). This is a detailed description of the item/construction, for example, giving degree of angle and length of a wheelchair ramp or dimension of a wheel chair accessible parking space.

Print Name of Person Writing Specifications — Enter the name of the person  completing the specifications.

Credentials/Title of Person Writing Specifications — Enter the credentials and title of the person completing the specifications.

Signature of Person Writing Specifications — The person must sign and date the form after the specifications are completed.

Signature of DSA Representative — The DSA representative must sign and date the form after the specifications are completed.

Section II

Section II is to be completed by the individual/LAR.

Print Name of Individual/LAR — Enter the name of the individual/LAR.

I AGREE / I DO NOT Agree with the proposed specifications — Check the appropriate box.

Comments — The individual/LAR should enter any comments, if applicable.

Signature of Individual/LAR — The individual/LAR must sign and date the form.

Section III

Signature of Case Manager — The Case Management Agency representative must sign and date the form after the specifications are completed.

Section IV

The landlord or owner of the property where the minor home modification is to be made must complete this section before the modification has started. The proposed modification must be described in Section I. This area may not be applicable for adaptive aid items.

I APPROVE / I DO NOT Approve of the modification — The landlord/property owner checks the appropriate box.

Print Name of Landlord/Property Owner — Enter the name of the landlord or owner of the property.

Signature of Landlord/Property Owner and Date — The landlord or owner of the property must sign and date the form.

Note: If the landlord or owner of the property does not approve of the proposed modification, the DSA cannot proceed with the requested minor home modification.