Form 3608 PDF Details

Understanding the intricacies of the Texas Department of Aging and Disability Services Form 3608, updated in February 2014, is essential when navigating the realm of home and community-based services (HCS). This comprehensive document serves as an Individual Plan of Care (IPC) that outlines the specific services required by an individual, incorporating details such as the service duration, effective dates, and Medicaid numbers. It addresses various facets of care, from residential support services and nursing to minor home modifications and cognitive rehabilitation therapy. Additionally, it involves a cooperative process between the service planning team, the program provider, and, critically, the individual or their legally authorized representative. An emphasis is placed on necessitating these services for the individual's health and welfare within the community, aspiring towards maximizing independence and ensuring community integration. The form also caters to emergency criteria adjustments and revisions without needing a meeting for certain IPC modifications, streamlining the process for urgent or minor changes. Furthermore, it highlights the financial management services alongside the county of service, painting a full picture of the care and administrative logistics involved. Critical in this documentation is the mutual agreement on the necessity, appropriateness, and cost-effectiveness of the services provided, ensuring all parties are aligned with the care objectives and expectations.

QuestionAnswer
Form NameForm 3608
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other nameshhsc 3608 template, hhsc ipc form, hhsc 3608 fill, hhsc 3608

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Texas Department of Aging

Form 3608

and Disability Services

February 2014-E

Home and Community-based Services

Individual Plan of Care (IPC)

Individual Name (Last, First, MI)

 

 

Medicaid No.

 

IPC Begin Date

IPC End Date

IPC Effective Date

 

 

 

 

 

 

 

 

Address (Street, City, State, ZIP)

 

 

Date of Birth

 

Age

Level of Need

CARE ID No.

 

 

 

 

 

 

 

Program Provider

 

 

Provider Component Code

Provider Contract No.

 

 

 

 

 

 

Financial Management Services Agency (FMSA)

 

FMSA Component Code

FMSA Contract No.

 

 

 

 

 

 

 

 

 

Residential Type

 

 

 

 

 

Location Code

County of Service

Foster/Companion Care

Own Home/Family Home

Supervised Living

Residential Support Services

 

 

 

 

 

 

 

 

 

 

IPC Type (check one)

Requires service planning team (SPT) and provider to hold an IPC meeting:

Initial (Enrollment)

or

Renewal

Transfer: Contract/Service Delivery Option

Revision to Reflect Person-Directed Plan (PDP) Change

Meets Emergency Criteria §9.166(d) (Check this box if revision is due to an emergency.)

Does not require SPT and provider to hold an IPC meeting:

Revision to increase/decrease an existing Home and Community-based Services (HCS) service. This option may not be used if the increase or decrease requires a new outcome, because the SPT and provider must meet to revise the PDP. The IPC effective date for an IPC increase/decrease must be on or after the date the provider notified the service coordinator (SC) in writing of the need to increase or decrease a current HCS service.

Reason for increase/decrease:

Revision to add/change a requisition fee only.

Non-HCS Services Provided by Family and Other Funding Sources

Type of Service

Funding Source

No. of Hours

No. of Days

Per Day

Per Week

 

 

 

 

Name of Provider

Form 3608

Page 2 / 02-2014-E

Home and Community-based Services

Individual Plan of Care (IPC)

Individual Name (Last, First, MI)

CARE ID No.

IPC Begin Date

IPC End Date

IPC Effective Date

IPC Service Information

Indicate need to increase or decrease an existing HCS service by entering an I (increase) or D (decrease) in the column next to the service.

Provider Service

I/D

Authorized

Provider Service

I/D

Authorized

Consumer Directed Service (CDS)

 

I/D

Authorized

 

 

Units

 

 

Units

 

 

 

 

Units

Adaptive Aids (AA)

 

 

Nursing – LVN (NUL)

 

 

 

Cognitive Rehabilitation Therapy (CRTV)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Adaptive Aids – Requisition Fee (AAR)

 

 

Nursing – Specialized LVN (NULS)

 

 

 

Employment Assistance (EAV)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Audiology (AU)

 

 

Nursing – RN (NUR)

 

 

 

Financial Management Services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Behavioral Support (BES)

 

 

Nursing – Specialized RN (NURS)

 

 

 

(FMS) Monthly Fee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cognitive Rehabilitation Therapy (CRT)

 

 

Occupational Therapy (OT)

 

 

 

Nursing – LVN (NULV)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day Habilitation (DH)

 

 

Physical Therapy (PT)

 

 

 

Nursing – Specialized LVN (NULSV)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dental (DE)

 

 

Residential Support Services (RSS)

 

 

 

Nursing – RN (NURV)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dental Requisition Fee (DER)

 

 

Respite Hourly (REH)

 

 

 

Nursing – Specialized RN (NURSV)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dietary (DI)

 

 

Social Work (SW)

 

 

 

Respite Hourly (REHV)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employment Assistance (EA)

 

 

Speech/Language Pathology (SP)

 

 

 

Support Consultation (SCV)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Foster/Companion Care (FC)

 

 

Supervised Living (SL)

 

 

 

Supported Employment (SEV)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Minor Home Modifications (MHM)

 

 

Supported Employment (SE)

 

 

 

Supported Home Living (SHLV)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Minor Home Modifications –

 

 

Supported Home Living (SHL)

 

 

 

 

 

 

 

 

Requisition Fee (MHMRE)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Totals from CARE Screen C62 (for all services)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CDS Estimated Annual Total

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Program Provider Estimated Annual Total

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IPC Estimated Annual Total

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are any services staffed by a relative or guardian?

Yes

No

Form 3608

Page 3 / 02-2014-E

Home and Community-based Services

Individual Plan of Care (IPC)

Individual Name (Last, First, MI)

CARE ID No.

IPC Begin Date

IPC End Date

IPC Effective Date

Service Planning Team: By signing below, you indicate your agreement that the HCS services for this individual are necessary to protect the individual's health and welfare in the community; are not available to the individual through any other source, including the Medicaid state plan, other governmental programs, private insurance or the individual's natural supports; are the most appropriate type and amount to meet the individual's needs; are cost effective; and are necessary to enable community integration and maximize independence.

HCS Program Provider/Individual/Legally Authorized Representative (LAR) Signature

Signature – Provider Representative

 

Printed Name

 

Date

 

 

 

 

 

Signature – Individual/LAR

 

Printed Name

Date

 

Individual/LAR participated by phone on:

 

 

 

 

 

 

 

 

 

 

Date

(1)If the individual/LAR participates in person and agrees with the IPC, the individual/LAR signs, prints his name and enters the date of the IPC meeting. If the agreement is obtained by phone, the provider checks the box and enters the date of agreement. The provider then sends a copy of the form to the individual/LAR for signature.

(2)For an IPC revision that adds/changes a requisition fee only, the provider enters “requisition fee only” in the individual’s signature line and enters the IPC effective date as the signature date.

DADS Review and Authorization (if required)

Local Authority/Service Coordinator (SC) Signature

Local Authority Name:

Signature – Service Coordinator

 

Printed Name

 

Date

(1)When the SC participates in the IPC meeting in person, the SC signs, prints his name and enters the date (on the signature line above) on the day of the meeting.

(2)When the SC participates in the IPC meeting by phone, the provider writes “participated by phone” on the SC signature line, prints the SC’s name and enters the date of the meeting.

(3)For an IPC revision that increases/decreases an existing HCS service and does not require an IPC meeting, the provider writes “notified SC” on the SC signature line, prints the SC’s name and enters the date this form was submitted to the SC. (Submission of this form to the SC serves as notification of an IPC revision that does not require an IPC meeting.)

(4)For an IPC revision that adds/changes a requisition fee only, the provider enters “requisition fee only” in the SC signature line and enters the IPC effective date as the signature date.

Signature – DADS Authorized Representative

Date

Service Coordinator Response

(For proposed service increase/decrease IPC revisions only)

Check one of the options below and return this form to the provider within two business days after the provider submits this notification of needed change to the SC.

SC agrees with the IPC revision. No IPC meeting is required.

IPC meeting is needed.*

Reason:

*Before checking this box, the SC contacts the provider and discusses any questions or concerns regarding the requested revisions. After the discussion, if the SC determines that an IPC meeting is needed, the SC checks the “IPC meeting is needed” box, includes the reason for the meeting, signs, prints name and returns this form to the program provider. The SC then schedules a meeting to occur with the individual/LAR and the program provider as soon as possible but no later than 14 calendar days.

Signature – Service Coordinator

Printed Name

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1. Start filling out your hhsc ipc form with a group of essential blank fields. Consider all of the information you need and make sure absolutely nothing is neglected!

Part no. 1 in completing hhsc 3608 printable

2. When the previous section is completed, go on to enter the applicable details in these - Revision to addchange a, NonHCS Services Provided by Family, Type of Service, Funding Source, No of Hours, No of Days, Per Day, Per Week, and Name of Provider.

hhsc 3608 printable completion process described (part 2)

3. This next step is generally hassle-free - fill out every one of the blanks in Provider Service, Units, Provider Service, Units, Consumer Directed Service CDS, Units, Adaptive Aids AA, Nursing LVN NUL, Cognitive Rehabilitation Therapy, Adaptive Aids Requisition Fee AAR, Nursing Specialized LVN NULS, Employment Assistance EAV, Audiology AU, Nursing RN NUR, and Behavioral Support BES in order to finish this segment.

Step # 3 of submitting hhsc 3608 printable

4. To go forward, this next step will require completing a few empty form fields. Examples of these are Totals from CARE Screen C for all, CDS Estimated Annual Total, Program Provider Estimated Annual, IPC Estimated Annual Total, Are any services staffed by a, and Yes, which are essential to carrying on with this particular form.

hhsc 3608 printable writing process outlined (portion 4)

5. The form needs to be wrapped up by dealing with this area. Here you'll see a comprehensive list of form fields that need accurate details for your form usage to be accomplished: HCS Program, Local AuthorityService Coordinator, Signature Provider Representative, Printed Name, Signature IndividualLAR, Printed Name, IndividualLAR participated by, Date, Date, Date, If the individualLAR participates, For an IPC revision that, only in the individuals signature, DADS Review and Authorization if, and Signature DADS Authorized.

The best way to fill out hhsc 3608 printable portion 5

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