Online Submission System

Thank you for visiting the Bureau of Long Term Care online submission system.

On this site you can download forms as well as upload documents.

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To have full access to the Online Forms Submission System, including receiving the most up to date version of all forms please enter your email below and select SUBSCRIBE.

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Welcome

What would you like to do?

I am the parent of a child who is already on the Katie Beckett (KB) waiver and I need to upload documents for redetermination.

NEW APPLICATIONS WILL NOT BE ACCEPTED IN THIS SYSTEM. For all new applications please contact Liberty Healthcare directly.

Email: idahoias@libertyhealth.com

Fax: 208-258-7985

Mailing address is provided in the application packet.

I am a provider for the Aged & Disabled (A&D) Waiver and Personal Care Service (PCS) programs and I need to upload or download forms.

I am a provider for the Aged & Disabled (A&D) Waiver and Personal Care Service (PCS) programs. I am submitting a Service Plan, RN Supervisory Nurse Visit form, or other supporting documents.

Please note: Only these specific documents may be uploaded using this link. For all other forms, you must select the second checkbox above.

I need to complete Case Management forms.

Cancel

Katie Beckett Page

Instructions to upload Katie Beckett documentation

Please note that only one document can be uploaded at a time. If you have multiple documents, you must enter them separately or combine into a single PDF file.

1. Enter the Medicaid Number for the child participant.

2. Navigate to the file for upload to your computer.

Drop file(s) here

		Select Files


		Select Files

Cancel

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Please use a browser with HTML5 support; or install Microsoft Silverlight v3 or later to view this content and have an ability to upload files.

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3. Select the file for upload.

4. Click the Open button.

5. Select the Upload button.

6. Verify that the selected document is uploaded in the Select File field.

7. Select Upload.

Upload

Cancel

PASRR Page

Preadmission Screening and Resident Review

Level 1 HW00087

Submission Information

Submitter First Name:*

Submitter Last Name:*

Submitter Phone Number:*

Format must be 000-000-0000

Submitter Email:*

Invalid Email format

Submitter County:*

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Initial Preadmission Screening

Resident Review/Status Change

Admission Date for Resident Review:

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Patient Information

First Name:*

Middle Initial:

Last Name:*

Mailing Address:*

City:*

State:*

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Zip Code:*

Invalid US Zip Code format

Date of Birth:*

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Phone Number:*

Format must be 000-000-0000

Medicaid ID Number:

Invalid Medicaid ID Number format

Last 4 Digits of Social Security Number:*

Invalid Social Security Number format

Sex:*

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Current Location Type:*

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Please Specify:*

Primary Care Physician Information

Primary Care Physician:

Physician Phone Number:

Format must be 000-000-0000

Receiving Nursing Facility Information

Receiving Nursing Facility Name:

Proposed Date of Admission:

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Receiving Nursing Facility Address:

Receiving Nursing Facility City:

Receiving Nursing Facility County:

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Receiving Nursing Facility State:

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Receiving Nursing Facility Zip Code:

Invalid US Zip Code format

Legal Representative Information

Check this box if this person has a legal representative

First Name:*

Middle Initial:

Last Name:*

Phone Number:*

Format must be 000-000-0000

Mailing Address:*

City:*

State:*

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Zip Code:*

Invalid US Zip Code format

Section I: Mental Illness

BOX 1: Does this person have any of the following disorders?

Do not list anxiety and depression in Box 2 if listed in Box1:

Schizophrenia Spectrum and Other Psychotic Disorders:*

Yes

Suspected

Depressive Disorders:*

Yes

Suspected

Anxiety Disorders:*

Yes

Suspected

Bipolar Disorders:*

Yes

Suspected

Somatoform Disorders:*

Yes

Suspected

Personality Disorders:*

Yes

Suspected

Post-Traumatic Stress Disorders:*

Yes

Suspected

Obsessive Compulsive-Related Disorders:*

Yes

Suspected

BOX 2: Does the individual have any of the following mental disorders?

Anxiety (Mild or Situational):*

Yes

Suspected

Depression (Mild or Situational):*

Yes

Suspected

BOX 3

Does the individual have a diagnosis of a mental disorder that is not listed in BOX 1 or BOX 2?

Do not list dementia here:

List Diagnoses:

Diagnosis

No data to display

Add another diagnosis

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BOX 4

Does the individual have a substance related disorder?

Do not list opioid dependence here:

List Diagnoses:

Diagnosis

No data to display

Add another diagnosis

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Is the NF need associated with this diagnosis?:*

Yes

Section II: Current Psychiatric Medications

BOX 5: Current Psychiatric Medications

Do not list medications used for a medical diagnosis, treatment of behaviors related to Dementia diagnosis, or hospice medications related to end of life.:

Medication

Dosage (Mg/Day)

Diagnosis

Started

No data to display

Add another diagnosis

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October 2026

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Section III: Symptoms

Box 6: Has the individual exhibited interpersonal symptoms or behaviors (not due to a medical condition)?

Serious difficulty interacting with others

Date Occured (If Known):

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Altercations, evictions, or unstable employment

Date Occured (If Known):

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Frequently isolating or avoiding others

Date Occured (If Known):

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Box 7: Has the individual exhibited any of the following symptoms or behaviors (not due to a medical condition)?

Serious difficulty completing age related tasks

Date Occured (If Known):

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Substantial errors with tasks in which she/he completes

Date Occured (If Known):

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Difficulty with concentration, persistence, pace

Date Occured (If Known):

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Box 8: Has the individual exhibited any symptoms related to adapting to change?

Self-injurious or self-mutilation

Date Occured (If Known):

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History of suicide attempt or gesture

Date Occured (If Known):

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Severe appetite disturbance

Date Occured (If Known):

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Serious loss of interest in things

Date Occured (If Known):

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Suicidal talk/ideations

Date Occured (If Known):

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Physical threats

Date Occured (If Known):

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Excessive tearfulness

Date Occured (If Known):

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Withdrawal due to adaptation difficulties

Date Occured (If Known):

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Physical violence

Date Occured (If Known):

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Hallucinations or delusions

Date Occured (If Known):

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Excessive irritability

Date Occured (If Known):

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Other major mental health symptoms, this may include recent symptoms that have emerged or worsened as a result of recent life changes as well as ongogin symptoms

Describe Symptoms:*

Date Occured (If Known):

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Section IV: History of Psychiatric Treatment

Box 9: Has the individual received any of the following mental health services?

Inpatient psychiatric hospitalizations

Date Occured (If Known):

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Partial hospitalization/day treatment

Date Occured (If Known):

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Residential treatment

Date Occured (If Known):

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Other

Please Specify:*

Date Occured (If Known):

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October 2026

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Box 10: Has the individual experienced significant life disruptions because of mental health symptoms?

Legal intervention due to mental health symptoms

Date Occured (If Known):

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Housing change because of mental illness

Date Occured (If Known):

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Suicide attempt or ideation

Date Occured (If Known):

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October 2026

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Jan	Feb	Mar	Apr
May	Jun	Jul	Aug
Sep	Oct	Nov	Dec

Other

Please Specify:*

Date Occured (If Known):

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October 2026

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Box 11

Has the individual had a recent psychiatric/behavioral evaluation?

Please attach this form in the supporting documents section if available.:

Date Occured (If Known):

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October 2026

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Jan	Feb	Mar	Apr
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Section V: Dementia

BOX 12: Does the individual have a PRIMARY diagnosis of dementia or Alzheimer's disease?

Yes

Box 13: Please select and attach corroborative testing or other information available to verify the presence or progression of the dementia.

Dementia work up

Mental Status Exam

Other

Please Specify:*

BOX 14: Current Antipsychotic Medications Used to Treat Dementia

Do not list medications like Namenda, Aricept, etc.:

Medication

Dosage (Mg/Day)

Diagnosis

Started

No data to display

Add another diagnosis

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October 2026

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Jan	Feb	Mar	Apr
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Section VI: Intellectual Disabilities & Developmental Disabilities

BOX 15: Does the individual have a diagnosis of intellectual disability (ID) - An intellectual disability is evidenced by an IQ of less than 70 based on standardized, reliable tests; onset before age 18?

Yes

BOX 16: Does the individual have presenting evidence of intellectual disability (ID) that has not been diagnosed?

Yes

Box 17: Does the individual have documented evidence of a related condition?

Related condition refers to severe, chronic disability that is attributable to condition related closely to intellectual disability, resulting in impairment of general intellectual functioning or adaptive behavior similar to ID and requiring similar treatment or services, onset before age 22; duration likely to last lifelong.:

Autism

Blindness

Closed head injury

Seizure Disorder

Cerebal Palsy

Deafness

BOX 18: Has the individual received services from, or been referred to, an agency or facility that serves individuals with intellectual disability?

Yes

Box 19: Are there substantial functional limitations in any of the following?

Related condition refers to severe, chronic, disability that is attributable to condition related closely to intellectual disability, resulting in impairment of general intellectual functioning or adaptive behavior similar to ID and requiring similar treatment or services, onset before age 22; duration likely to last lifelong.:

Only check boxes below if patient has an intellectual or developmental disability.:

Mobility

Learning

Capacity for living independently

Self Care

Self Direction

Understanding/use of language

Supporting Documents

Please attach the following as available

1. Current Pt. Prognosis
2. H&P including Social History
3. Provider Level of Care with Provider Attestation
4. Discharge Summary with Current Medication Order

Attach files here

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Signature and Attestation

Signature

Type your full name here to sign:*

Credentials:*

Date:*

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October 2026

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By checking this box, I certify that I have completed this form accurately to the best of my ability, and have given the patient and/or their legal guardian the notification of Mental Health/Developmental Disability review mandated by Omnibus Budget Reconciliation Act of 1987, per Section 1919 (b)(3)(F)

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A&D Waiver/PCS Forms Page

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A&D Waiver/PCS Upload Forms Page

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Please note that only one document can be uploaded at a time. If you have multiple documents, you must enter them separately or combine into a single PDF file.

1. Navigate to the file for upload to your computer.

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A&D Waiver/PCS Fillable Files Download Page

Instructions to Download Fillable Form

The Following is a list of all form templates available online. The forms are to be used for both adult and child participants unless otherwise specified. Please carefully review the document name and description to ensure you are downloading the correct form. Select the DOWNLOAD icon to download the template to your computer.

Document Name

Description

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A&D Waiver/PCS Page

Instructions to Upload Forms or Documentation

Please note that only one document can be uploaded at a time. If you have multiple documents, you must enter them separately or combine into a single PDF file.

1. Enter the Medicaid Number for the participant.

2. Navigate to the file for upload to your computer.

Drop file(s) here

		Select Files


		Select Files

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Please use a browser with HTML5 support; or install Microsoft Silverlight v3 or later to view this content and have an ability to upload files.

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3. Select the file for upload.

4. Click the Open button.

5. Select the Upload button.

6. Verify that the selected document is uploaded in the Select Files field.

7. Select one of the following checkboxes.

Service Plan

RN Supervisory Form

Supporting Documents

8. Select Upload.

Upload

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Case Management Page

Instructions to use Case Management Forms

Following are a list of interactive forms for Case Management. Select the OPEN icon and complete the form in it's entirety and select Submit. The form will be sent to the BLTC automatically. A PDF version will also be populated to download for your records.

Document Name

Description

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