NOTIFICATION OF ACTIONS TO BE TAKEN
To:
Address:
In accordance with CRS 27-10.5-107 and Division for Developmental Disabilities’ Rules and
Regulations 16.322 (D) effective 01-01-01, notice that the following action(s) will be taken which
affect the status of
in programs and services provided through Imagine!.
Is no longer eligible for services.
Programs/services are to be terminated.
Programs/services in the IP are to be reduced or denied.
Suspension of right(s).
Suspension from services/supports.
This action will be effective
xx/xx/xx
DESCRIPTION OF ACTION(S) TO BE TAKEN:
REASONS FOR ACTION(S) BEING TAKEN:
If you are in disagreement with the action(s) being taken a conflict resolution procedure through
which you may appeal the decision has been enclosed. Please contact _________________, at
_______________if you have questions, or require assistance to implement the procedure.
Names & contact information for advocates able to assist with the procedure are listed on the back
of this form.
Signature
Title
Updated 4/25/12
Date
Association for Community Living of Boulder County
5744 North Seventy First Street
Longmont, Colorado 80503
(303) 527-0888
General Information: [email protected]
Legal Center for People with Disabilities & Older People
455 Sherman
Denver, CO 80203
(303) 722-0300
Mediation
This may be arranged through Imagine! liaisons
Rebecca Novinger (720) 399-4190 or through
State of Colorado Office of Field Services 1-888-815-6684
1400 DIXON AVENUE LAFAYETTE, COLORADO 80026-2790
PHONE: 303-665-7789 FAX: 303-665-2648
WEB: http://imaginecolorado.org