Free Individual Service Plan - Individual Outcomes - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-20445A (08/2008)

STATE OF WISCONSIN

INDIVIDUAL SERVICE PLAN ­ INDIVIDUAL OUTCOMES
1. Waiver Program: CLTS Waiver (Indicate Target Group): CIP 1A CIP 1B BIW 3. Name - Applicant/Participant 5. Outcome Number 2. Name - Support and Service Coordinator/Care Manager, Agency DD CIP II MH COP-W PD COR 4. Medicaid ID Number

6. Desired Outcome(s) Addressed in Service Plan

7. Outcome Status or Progress Update

8. Date

F-20445A Page 2

INSTRUCTIONS ­ INDIVIDUAL SERVICE PLAN ­ INDIVIDUAL OUTCOMES
No. Title Description

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Waiver Program Support and Service Coordinator/Care Manager, Agency Participant Name Medicaid ID Number Outcome Number Desired Outcome(s) Addressed in Service Plan Outcome Status or Progress Update

Indicate the waiver program serving the applicant/participant Enter the Support and Service Coordinator/Care Manager and Agency Name Enter the full legal name: last name, first name, middle initial and any suffix (e.g. Jr.) Enter the ten digit Medicaid Number Assign a number corresponding to each individual outcome listed. The outcomes should be listed in order of their priority (as designated by the applicant/participant) Describe the individual outcome identified by the applicant/participant. Each SPC code or paid/unpaid informal support listed on the 20445 should support the pursuit of an individual outcome. Note any progress or update status of the individual outcome. Note `new' if this is a new outcome being added. Indicate person(s)/agency responsible or who have a role in the attainment of the outcome. Enter the date the outcome was developed, updated or achieved, as applicable.

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Date