Free 48316 - Indiana

PROFESSIONAL/CONSULTANT DOCUMENTATION FOR ICF/MR
Surveyors: Complete this form for each facility and return with the packet

Name Administrator Program Director QMRP Social Worker *Psychologist *Behavior Spec/Clinician Medical Director Dentist Pharmacy R.N. L.P.N. Transfer Agreement Emergency Medical Emergency Dental Dietitian *Speech Therapist *Occupational Therapist *Physical Therapist *Recreation Day Program D & E Team Other *Optional if there are no identified needs. State Form 48316 (3-97) ICF/MR 6

Qualifications

On Staff/or Contract

Not Applicable Not Applicable Not Applicable