Free HSRS Family Support Program Module - Wisconsin


File Size: 35.5 kB
Pages: 2
File Format: PDF
State: Wisconsin
Category: Health Care
Author: DHS
Word Count: 605 Words, 3,962 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms1/f2/f20468.pdf

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DEPARTMENT OF HEALTH SERVICES Division of Enterprise Services F-20468 (Rev. 08/2008)

STATE OF WISCONSIN SOS Desk (608) 266-9198 Statutory authority: S. 46-985(3)(f) and HFS 65.05(9) Completion of this form meets the requirements of the State/County contract specified under the Wisconsin Statutes. S. 46.031(2g)

HSRS FAMILY SUPPORT PROGRAM MODULE
Child and Family Information
Screen 59 New or 84 Update 1 Worker ID 4a Last Name 5 Birthdate (mm/dd/yyyy) 6 Sex F M ) 9 End Date 10 Closing Reason 11 Alternate Care Type (Required if closing reason is 44) 1 Foster care 4 Center developmentally disabled 2 Group home 5 Mental health institute 3 Residential care center 6 Nursing home 7a Hispanic / Latino Y = Yes N = No MODULE TYPE 5 2 Client ID 4b First Name 3 MA Number / Social Security Number 4c Middle Name 4d Suffix

7b Race (Circle up to 5) A = Asian B = Black or African American P = Native Hawaiian or Pacific Islander

I = American Indian or Alaska Native W = White

(Module Key: 8 Start Date

12 Client Characteristics

13 Diagnosis

14 Assistance Needed for Personal Care 1 Child unable to help him / herself 2 Child needs assistance with some activities 3 Child does not need assistance 16 Limitations in Verbal Skills 1 Child is nonverbal 2 Child has very limited verbal skills 3 Child is fully verbal 18 Emotional / Behavioral Issues 1 Child presents significant behavioral challenges 2 Child presents minor behavioral challenges 3 Child has no behavioral challenges

15 Limitations in Mobility 1 Child cannot walk 2 Child needs assistance in walking 3 Child does not need assistance in walking 17 Limitations in Cognitive Abilities 1 Child has severe developmental delays 2 Child has moderate / mild developmental delays 3 Child has no cognitive delays 19 Medical Needs 1 Apnea monitor 6 Acute psychiatric episode 2 Gastrostomy / tube feed 7 Ongoing medications 3 Tracheotomy 8 Degenerative disorder 4 Oxygen dependent 9 Surgery this year 5 Heart monitor 10 Hospitalization this year 23 Parent's Special Needs 1 Developmentally disabled 2 AODA 3 Mentally ill 5 30,001 - 40,000 6 40,001 + 4 Physically disabled 5 Medical condition 25 Family Cost Share

20 Family ID

21 Number of Caregivers

22 Adopted Child Yes No

24 Income Range 1 0 - 10,000 2 10,001 - 15,000

3 15,001 - 20,000 4 20,001 - 30,000

Screen 79 26 Has child returned from alternate care? Yes No If "Yes" enter alternate care type:

27 Reporting Year Registration 0000

1 Foster care 4 Center for developmentally disabled 2 Group home 5 Mental health institute 3 Child caring institution 6 Nursing home 28 Has family considered out of home placement? 29 Is family in a crisis situation? Yes Yes Yes Yes Yes Yes No No No No No No Yes Yes Yes Yes Yes Yes No No No No No No

DEPARTMENT OF HEALTH SERVICES Division of Enterprise Services F-20468 (Rev. 08/2008)

STATE OF WISCONSIN

2

EXPENDITURES FOR FAMILY SUPPORT SERVICES
Screen 93 (Module Key: _____________________ ) 31 Other Programs Used 2 BCPN 4 SSI-E 3 SSI 5 Katie Beckett Prog. No. 34 Subprogram 6 Birth to 3 35 Estimated Annual Costs 32 Voluntary Resources 1 ________________________________________________________ 2 ________________________________________________________ 36 Cost Code A - Add S - Subtract R - Replace 37 Actual Costs 38 Delivery (mm) (yyyy) 39 Service Start Date 40 Service End Date 30 Next Review Date 33 Target Group* * Refer to deskcard 41 Provider Number

A Architectural modification of home B Child care C Counseling / therapeutic resources D Dental and medical care not otherwise covered E Diagnosis and evaluation specialized F Diet, nutrition and clothing specialized G Equipment / supplies specialized H Homemaker services I In-home nursing services attendant care

J Home training / parent courses K Recreation / alternative activities L Respite care M Transportation N Utility costs - specialized O Vehicle modification P Other, as approved by DHFS 42 Subprogram P, text: * Refer to deskcard