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Please complete all applicable sections of this application and checklist. Please note the following : If you are interested in participating in the voluntary conversion of ICF/MR beds to waiver beds, Please attach a statement of your interest to this application. For more information you may contact Debbie Jenkins at (614)387-0578. If you are relocating licensed beds and the existing facility is currently certified as an ICF/MR, you will need to contact Biljana Manev at the Ohio Department of Job and Family Services at (614) 752-3573 at least 90 days prior to the proposed relocation date. An operator of a licensed facility, which will deliver services to waiver consumers, shall apply for and must be certified as a HCBS waiver provider in order to receive reimbursement for waiver services. Contact the Provider Certification office at (877) 289-3636, if you need an application. If relocating licensed beds, you must notify the local county Department of Job and Family Services of the change of address for involved individuals.
1/23/12 1 Please complete all applicable sections of this application and checklist. Please note the following: If you are interested in participating in the voluntary conversion of ICF/MR beds to waiver beds, please attach a statement of your interest to this application.
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