Free 51919.FH11 - Indiana

ANNUAL IFSP CHECKLIST
State Form 51919 (10-04) / BCD 0116 Indiana Family and Social Services Administration

Name of child Name of Service Coordinator

Date of birth (month, day, year) County

INCLUDE ALL DOCUMENTS IN THE ORDER LISTED BELOW:
Individual Family Service Plan effective day following expiration of current plan Physician signature on IFSP Services page (this must accompany the plan) Completed eligibility form Signed Cost Participation Co-Payment form generated by SPOE if changes in income have occurred CRO Release signed and dated by parent/guardian and Service Coordinator Documentation of Receipt of Family Rights/Consent to Evaluate/Assess signed and dated by parent/guardian and Service Coordinator Medical Reciprocal Release for childs Primary Medical Provider and any other appropriate medical providers signed and dated by parent/guardian and Service Coordinator Reciprocal Releases for First Steps Providers and general releases for others (as applicable) signed and dated by parent/guardian and Service Coordinator Completed and signed Physicians Health Summary Copy of 10 day Written Prior Notice letter informing the family about the IFSP meeting Request for Authorization for IFSP Team meeting Request for Authorization for Eligibility Determination (ED) Team set up for length of IFSP Ongoing Provider(s) Progress Summaries Annual ED Team, Multidisciplinary Evaluation Report

The Service Coordinator must complete this checklist and place it on top of all the documents listed above. All documents must be placed in the order listed above and paper clipped together when sent to the SPOE. If all information is not present, no data entry will be done. The Service Coordinator will receive a MISSING DATA ENTRY form from the SPOE. The entire packet must be mailed or dropped off during normal SPOE hours. No documentation will be accepted via fax to the SPOE. The SPOE cannot process an annual IFSP without all of the information listed above.