PROVISIONAL PLAN OF CARE CHILDREN WITH SERIOUS EMOTIONAL DISTURBANCE MEDICAID WAIVER
State Form 51551 (3-04) / TS 0002 Name of recipient Medicaid number (RID) Address (number and street, city, state, ZIP code) Telephone number Name of parent / guardian Date of birth (month, day, year) Date plan completed
The information contained on this form is CONFIDENTIAL according to IC 16-39-2.
LOC approval date
Presenting Problem: Describe problem and need for provisional plan of care.
Initial Plan: Effective From:
MEDICAID STATE PLAN AND WAIVER SERVICES
To:
PROVIDER TOTAL UNITS
Proposed Slot Number:
COST PER UNIT MONTHLY COST TOTAL AMOUNT COST START DATE END DATE
Wraparound Facilitation
Signature of parent / guardian Signature of Wraparound Facilitator / CMHC
Date (month, day, year) Date (month, day, year)