Home and Community Based Services Manual


5.00 Appendix 5 Reversal of Adverse Action Notice

The Reversal of Adverse Action Notice form for Home and Community Based Services (HCBS) shall be utilized to notify current or potential participants and/or authorized representatives (e.g., guardian, or someone with a signed Authorization for Disclosure of Consumer Medical/Health Information that is in effect) that the Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS) has reversed its previous decision regarding an adverse action. The Department of Social Services (DSS), Division of Legal Services (DLS), and the DSDS HCBS Hearings Representative shall also be notified of the reversal when necessary.

INSTRUCTIONS 

DSDS staff shall enter the following information in the appropriate fields: 

  • Current or potential participant Information
    • Name
    • DCN
    • Date notice is being mailed
    • Address
    • Phone number (include extension when appropriate) 

NOTE: When the current or potential participant has a guardian, the guardian's information shall be entered in this section. 

  • Check the appropriate box or boxes regarding the original adverse action.
  • Check the box in the last section ONLY when reversing an adverse action that has been submitted to DLS
  • Enter the address of the appropriate Regional Administrative Office.
  • DSDS staff information
    • Signature and
    • Printed name
    • Phone number (include extension when appropriate)
    • Address 

DISTRIBUTION 

  • The original form shall be mailed to the participant and/or their authorized representative.
  • A copy is maintained in the participant’s electronic case record. 

NOTE: If a hearing request has already been forwarded to DLS, a copy of the Reversal of Adverse Action Notice shall be mailed to the appropriate DLS Regional Office and DSDS HCBS Hearings Representative.

Table of Contents

On this page