Free 45994.FH8 - Indiana

PLAN OF CARE FOR: C.H.O.I.C.E. OTHER WAIVER IPAS Only PASRR / MI or PASRR / DD
State Form 45994 (R3 / 7-01) BAIS 0019 Approved by State Board of Accounts, 2001

* THIS STATE AGENCY IS REQUIRING DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER PER IC 4-1-8-1. THE INFORMATION OBTAINED ON THIS FORM IS CONFIDENTIAL UNDER STATE AND FEDERAL REGULATIONS. THIS INFORMATION WILL NOT BE RELEASED EXCEPT AS PERMITTED OR REQUIRED BY LAW OR WITH THE CONSENT OF THE APPLICANT.

Last name Medicaid number Social Security number *

First name Date plan completed

Middle initial

GOAL

-

Area agency on aging number

PROBLEM STATEMENT

GOAL / OBJECTIVE

OBJECTIVES

PLAN OF CARE - EFFECTIVE FROM:
SERVICE PROVIDER FUNDING SOURCE FREQUENCY TOTAL UNITS COST PER UNIT

TO:
TOTAL COST MONTHLY COST START DATE END DATE

C.H.O.I.C.E. PROGRAM
I have reviewed the services contained in this plan, and I choose to accept this plan and the services explained to me. I have reviewed the services contained in this plan, and I choose to accept this plan and the services explained to me. I hereby agree to notify the case manager of any changes in my income or any changes that may affect the plan of care or my monthly C.H.O.I.C.E. cost share percentage of __________________ , which equals $ _____________________________ . Signature of Client Signature of Client Representative Signature of Case Manager Signature of AAA Signature of Physician (Medically Frag. Child Waiver Only) Signature of IDDARS Service Coordinator (D.D. Waiver only, BDDS Placement Authority) First Quarter Initials: ______________ Date: _______________ Second Quarter Initials: ______________ Date: _______________ Relation C.M. Code # Date Date Date Date Date Date Third Quarter Initials: ______________ Date: _______________