Free 51551.FH11 - Indiana


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Pages: 1
File Format: PDF
State: Indiana
Category: Government
Author: mscherer
Word Count: 120 Words, 818 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.state.in.us/icpr/webfile/formsdiv/51551.pdf

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Preview 51551.FH11
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)