Thank you for participating in our survey. Your feedback is important.

The purpose of this survey is to allow individuals the opportunity to respond to a set of questions from their perspective that are being asked to providers regarding the new CMS (Centers for Medicare and Medicaid Services) community setting rules. These rules strengthen the requirements for personal autonomy, community integration, and choice in home and community based services through Medicaid.  Your feedback is very important to us.

Please select an answer for each question from these choices:

Yes = service site meets HCBS characteristics as outlined in the question

No = 1) HCBS characteristics are not met, 2) setting cannot conform, or 3) setting is institutional in nature, e.g. hospital, ICF/ID, nursing facility, or institution for mental disease (IMD)

This section identifies the individual and the provider setting location and type so the information can be compared with the information from the provider. This is all kept confidential.

You will be asked to provide some personal information regarding your name, your provider's name, what waiver program you are enrolled in, the provider site address, whether it is a residential or non-residential services and the type of service.

This will allow your answers to be matched to the provider answers for comparison purposes

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* What is the name of the member receiving services in this setting? Optional

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* Name of person completing survey if different than above:

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* If completing the survey for the member, what is your relationship to the member? 

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* Provider Name:

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* Waiver/Program Name:

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* Site address:

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* Site Type:

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* Service Type:

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