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AAU Form Update: Changes to Environmental Modification Forms

July 5, 2011

As mentioned in the AAU Update sent on May 17th, we are in the process of converting all of our forms to meet the OKDHS guidelines for ADA compliance. The forms used to request an Environmental Modification have also been revised and updated. One of the purposes in revising the forms is to have all of the information required for an Environmental Modification request on one set of forms. Complete information on the forms should reduce the need for multiple communications between AAU and the Case Manager concerning the request.

The new forms are:

02CB031E, Environmental Modification Decision Tool: This form replaces ADv6d, Request for Environmental Modification.

This form should be used by the Case Manager and Service Team to review, after all alternative options are explored, whether the proposed Environmental Modification will meet the service definition of promoting independence and preventing premature institutionalization.

02CB032E, Environmental Modification Permission and Verification: This form combines ADv6d5, Owner's Permission to Modify Property, and ADv6d3, Verification of Service Delivery, for all environmental modifications except Durable Medical Equipment.

This form is used to verify that the home and property owner agree to permit permanent modifications to the home and property. Following the modification, the form is also used to verify that the modification was completed in accordance with the request and that the modification meets the needs of the Member. To request permission to install Durable Medical Equipment, please use form 02CB034E, Owner's Permission to Modify Property.

NEW 02CB033, Level of Function and Environmental Assessment:
This form is to be given to the physical or occupational therapist for the pre-modification assessment of the member’s level of function and need for an environmental modification. This form will be submitted to ADvantage Administration with form 02CB033E Environmental Modification Decision Tool, and will replace the therapist’s use of individual provider agency forms.

02CB034, Owner's Permission to Modify Property: This form replaces the ADv6d5, Owner’s Permission to Modify Property.

This form is to be used only for Durable Medical Equipment not to include grab bars to be installed inside the bathroom and Environmental Modifications. Bathroom grab bars and Environmental Modifications have separate forms on which to document owner’s permission. For Environmental Modifications, please use Form 02CB032E, Environmental Modification Permission and Verification. For bathroom grab bars, use form 02CB035E, Request for Bathroom Grab Bars.

NEW 02CB035, Request for Bathroom Grab Bars:
This form is used by the Case Manager to provide required information related to a Service Plan request for grab bars. This form is to be used only for grab bars to be installed in the bathroom. This form must be submitted with form 02CB011E, Service Plan Cost Sheet, or form 02CB012E, Service Plan Cost Sheet Addendum. To request grab bars for other locations, please use form 02CB034E, Owner's Permission to Modify Property.

Forms and instructions are located on the OKDHS ADvantage Administration Unit website ( Once on the website, you will see a list of all forms and instructions.

If you have any questions or concerns regarding the information provided above, please feel free to contact us via email at Provider Questions.

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