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Form preview

Freedom of Choice Waiver

Choose the waiver program and prepare the supporting information and documents.

Waiver program and budget
Patient information
Support coordinator

Required PDF documents

Each item will have a secure PDF upload area when submission is enabled.

Signed FOCFreedom of Choice formPDF upload placeholder
90L formRequired supporting formPDF upload placeholder
CPOC pages 1–17Plan of carePDF upload placeholder

Privacy Notice

Please review Healthcare Warehouse's Notice of Privacy Practices before completing this waiver request.

Download the Privacy Notice (PDF)

Preview only: acknowledgment will be required when secure submission is enabled.

What happens next

Healthcare Warehouse will prepare a calculation sheet and forward it to the support coordinator. Supplies are shipped after prior authorization is issued.