Care Coordination Resources
Minnesota Senior Health Options (MSHO)
Care Plan Letter
Care Plan Signature Letter
Change in Contact Info for Care Coordinator
Change of Care Coordinator Letter
Member Change Letter
Provider Care Plan Cover Letter
Provider Care Plan Summary Letter
Provider Engagement Letter (New 1/1/2022)
Refusal Letter (New 1/5/2022)
Unable to Reach Member Letter
Welcome Letter - Member in Nursing Home
Welcome Letter - Member on CAC, CADI, DD, or TBI Waiver
When To Call Your Care Manager
Additional or Substitute Home and Community Based Service Exception Request Form
Care Coordination Appointment Reminder Form (Revised 1/1/2022)
Collaborative Care Plan - PDF | Collaborative Care Plan - Word | Collaborative Care Plan Instructions
Customized Living Verification Code Form | Customized Living Verification Code Guidelines
Death Notification Form
Dental Kit Form
Health Connect 360 Referral Form
Home Health Communication Form | Home Health Communication Form Example
How to Safely Dispose of Medication (Revised 1/1/2022)
Institutional Health Risk Assessment-PDF (New 1/1/2022)
Institutional Health Risk Assessment-WORD (Revised 1/19/2022)
Lutheran Social Service of Minnesota Community Companion Authorization Request Form-WORD
Lutheran Social Service of Minnesota Community Companion Authorization Request Form-PDF
Medication Toolkit Order Form
MOM’s Meals MSHO Supplemental Benefit Form
MSHO AA/NA Ride Request Form
MSHO Supplemental Benefit Form
Memory Kit Order Form
Individual Home Supports Form (Revised 2/16/2022)
Nursing Home Face Sheet
Assessment Log (formerly Part C) (Revised 1/1/2022) | MSHO Activity Reporting Log Tip Sheet (Part C Log) (Revised 2/24/2022) | MSHO Tips for Completing Part C Log
Reemo Smartwatch Order Form (Revised 5/11/2022) | Reemo Smartwatch Overview
Refusal Support Plan-WORD (New 1/1/2022)
Refusal Support Plan-PDF (New 1/1/2022)
Release of Information Form
Request to Exceed Case Mix Cap
Strong & Stable Kit Order Form
Transitional Health Risk Assessment Form - Word
Transitional Health Risk Assessment Form - PDF
UTR Support Plan-WORD (New 1/1/2022)
UTR Support Plan-PDF (New 1/1/2022)
Waiver Service Approval Form (Revised 4/4/2022)
- Used by the PCA agency when a member is due for their annual PCA assessment and must send it 60 prior to the end of the PCA authorizations.
- Used when a DTR needs to be issued for services or an assessment (i.e., Early assessment, Refusal or Unable to reach).
- Member has selected a PCA provider agency.
- Used to approve or DTR extended PCA services.
- Used when the CC is reporting a change or new PCA provider agency.
- Approve 45 day temp start/Increase of PCA services.
PCA Coverage Policy (The PCA provider agency is required to notify UCare of a provider change however, the care coordinator may report this information to UCare in behalf of the provider).
- Used by providers when a member changes to a different PCA provider agency.
- Used by providers when a member previously had not selected a PCA provider agency at the time of the assessment but has now made their selection.
- Used to request a transfer of a PCA Authorization from another health plan to UCare.