Purchase Order for Individuals Receiving Community Supports
                                                                                                                                                                                                                    Under the Self Directed Model
   This document is intended to be used by individuals and their families to select the supports they want to purchase in support of their Individualized Service Plan.  This is not an allocation of services.  Each individual is given a resource 
   allocation to be used in the budgeting process.  This Purchase Order must be submitted to BHDDH for approval before Service Allocations can be assigned.  If approved, then service allocations will be assigned.
   Name of Participant Submitting this Purchase Order                                                                                                                                                                                                                                                                                                                                                                                                             ANNUAL RENEWAL
   Contract Dates                                                                                                                                                                                                             -                                                                                                                                                                                                           No of Weeks                                       0
   Social Security Number                                                                                                                                                                                                                                                        Client Code:
   PART A: Support Facilitation is required in each individual's Personal Budget                                                                                                                                     
          The agency you have selected as your FI is ……..
          The name of your Agency Contact is …                                                                                                                               PROGRAM:          FINANCE: 
   Resource Allocation Amount (Annual) Used for Self Directed Budgeting                                                                                                                                                                                                                                                                                                                                                                                                                          $0.00
   PART B: Community Supports, Day Activities or Self-Directed Services
   Make your selection(s) related to Day Activities or self-directed services.  Enter all items you wish to purchase.  Enter only on those lines where you are making a service request.  Leave the remaining lines blank.
                                                                                                                                  PER                                               Blended 
 COMMUNITY                                                                                                                  WEEK/PER                                               Rate Per                                                                                                                                                                                                                                                                                     Amount Used 
 SUPPORTS                                                                              RATE                HOURS               MONTH                  ANNUAL                           Unit*                    Units              1/1/-3/31/16                    $             4/1-6/30/16                    $               7/1-9/30/16                      $             10/1-12/31/16                      $                                                                 in Budget
          PAY PERIODS PER QUARTER                                                                                                                                                                                                                   -                                           -                                                -                                                -   
          COMMUNITY SUPPORTS
          T2017 U2                                  Staffing                       $          -              -               -     $              -                                    $0.0000                       -                         -                 -               -                  -                  -                  -                  -                  -                 -                  -                      -   
          T2017 UD U2                               Professional                   $          -              -                                    $              -                     $0.0000                       -                         -                 -               -                  -                  -                  -                  -                  -                 -                  -                      -   
          T2017 L9                                  S110
          T2025 U2                                  W/COMP
          TOTAL                                                                                                                                   $              -                                                      -                      -                 -               -                  -                  -                  -                  -                  -                 -                  -     $               -   
          DAY SUPPORTS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
          T2021 UA U1                               Staffing                                                                                      $              -                     $0.0000                       -                         -                 -               -                  -                  -                  -                  -                  -                 -                  -                      -   
          T2021 L9                                  S110                                                                                          $              -                     $0.0000                       -                         -                 -               -                  -                  -                  -                  -                  -                 -                  -                      -   
          T2021 L9 U1                               Professional                                                                                  $              -                     $0.0000                     0                           -                 -               -                  -                  -                  -                  -                  -                 -                                                                                               -   
          T2025 U2                                  W/COMP                                                                                        $              -                     $0.0000                     0          0              -                 -               -                                                                                                                                                                                                                  -   
          TOTAL                                                                                                                                   $              -                                                   -                         -                 -               -                  -                  -                  -                  -                  -                 -                  -     $               -   
          RESPITE (including PR Tax)                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
          T1005 U2                                  Staffing                                                                                      $              -                     $0.0000                       -                         -                 -               -                  -                  -                  -                  -                  -                 -                  -                      -   
          T1005 L9                                  S110                                                                                                                                                                                                                                                                                                                                                                                                                                                   
          TOTAL                                                                                                                                   $              -                                                   -                         -                 -               -                  -                  -                  -                  -                  -                 -                  -     $               -   
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
          SUPPORTED EMPLOYMENT (including PR Tax)                                                                                                                                                                                                                                                                                                                                                                                                                                                          
          T2019 U2                                                                                                                                $              -                     $0.0000                       -                         -                 -               -                  -                  -                  -                  -                  -                 -                  -                      -   
          T2019 L9                                  S110                                                                                                                                                                                                                                                                                                                                                                                                                                                   
          TOTAL                                                                                                         0                    0  $              -                                                     -                         -                 -               -                  -                  -                  -                  -                  -                 -                  -     $               -   
          JOB DEVELOPMENT OR ASSESSMENT
          TOTAL                                                                                                         0                    0  $              -                                                     -                         -                                            -                                               -                                                -                                               -                                   $               -   
 CLIENT NAME                                                                    0                                                                                                                              Units              1/1/-3/31/16                    $             4/1-6/30/16                    $               7/1-9/30/16                      $             10/1-12/31/16                     $                                                                       PAGE 2 
 SELF DIRECTED 
 SERVICES
   SUPPORT FACILITATION                            T2022 UA U2  $          -                                                                      $              -                     $192.14                      -                                                 -               -                  -                  -                  -                  -                  -                                                                              -                      -   
   SUPPORTS BROKERAGE T2041 U2
                                                                                  $          -                                                    $              -                       $12.50                     -                         -                 -                                                  -                                                -                                               -                                               -                      -   
          ROUNDING                                                                                                                                                                                                                                                                                                                                                                                                                                                             $               -   
          TOTAL                                                                                                                                                                                                     -                         -                 -               -                  -                  -                  -                  -                  -                 -                  -     $               -   
   Total Allocation                                                                                                                                                                                                                                                                                                                                                                                                                                                            $               -   
   Units per quarterly allocation                                                                                                                                                                                      -                      -                                           -                                                -                                               -                                               -                                                    -   
   Dollars per quarterly allocation                                                                                                                                                                                               $            -     $          -     $          -     $           -     $             -     $           -     $             -     $           -     $            -     $           -     $               -   
   * The Blended Rate Per Unit cannot exceed the rate paid to agencies for the same service.
          Signature of Participant (or Legally Authorized Representative)                                                                                                                                   Date (month/day/year)
          Signature of Representative from Fiscal Intermediary                                                                                                                                              Date (month/day/year)