Living Arrangement Statement-2026

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The document outlines the Medicaid Waiver Consumer Choice of Services/Living Arrangement Statement (DS 2200) for the State of California's Department of Developmental Services. It details the process by which consumers, or their legal representatives, can choose between various living arrangements and services under the Medicaid Waiver Program. The form requires identification information, signatures from responsible parties (parents, guardians, or legal representatives), and provides options for disenrollment from the program. It emphasizes the consumer's right to be informed about available services and their right to a fair hearing if services are not provided.

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How to use or fill out DS 2200 Medicaid Waiver Consumer Choice of Services/Living Arrangement Statement

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Click ‘Get Form’ to open it in the editor.
Begin by entering the consumer's full name in the 'Consumer Identification Information' section, along with the date of choice, unique identifier (UCI), and date of birth.
For minors, select who is making the choice (parent/legal guardian/legal representative) and ensure they sign and date the form. For adults, have them sign or mark their choice, ensuring a witness signs as well.
In Section III, indicate the chosen living arrangement by marking one of the options: A (long-term health facility), B (community care residential facility), or C (other).
If applicable, complete the disenrollment section by marking your choice to terminate Medicaid Waiver participation and signing with the date.
Use the comments section for any additional clarifications regarding choices made or signatures provided.

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