Free 51921.FH11 - Indiana

SERVICE CHANGE TO THE IFSP CHECKLIST
State Form 51921 (10-04) / BCD 0117 Indiana Family and Social Services Administration

All documents listed must accompany changes to the existing IFSP.
Name of child Name of service coordinator Date of birth (month, day, year) County

Include all documents in the order listed below: For all additions or increases in services: Completed IFSP change page with parent signature, Service Coordinator signature and primary physician signature (The physicians signature and the parents signature may be on two separate sheets or you may send a physician prescription if it reflects the exact level of service on the change page) Copy of 10 day Written Prior Notice letter informing the family Primary care physician prescription or order listing the exact service to be provided (If no physician signature is on the change page) Documentation of Team Discussion Form regarding an increase or addition in service(s) Outcome page if no outcome exists in the IFSP relating to the service being added For decreases in or a termination of services: Copy of 10 day Written Prior Notice letter informing the family Completed IFSP change page with parent signature and Service Coordinator signature Documentation of Team Discussion Form regarding a decrease in or termination of service For changes in providers: Completed IFSP change page with parent signature and Service Coordinator signature The start date for any new or changed service is the date that the form is signed by the parent or the physician, whichever is later. It is illegal to back-date the family or the physician signature. The Service Coordinator must complete this checklist and place it on top of all documents listed above. All documents must be placed in the order listed above and clipped together when sent to the SPOE. If all information is not present, no data entry will be done and the Service Coordinator will receive a MISSING DATA ENTRY form from the SPOE. THE ENTIRE PACKET MUST BE MAILED OR DROPPED OFF DURING NORMAL SPOE HOURS. NO DOCUMENTATION WILL BE ACCEPTED VIA FAX TO THE SPOE.