Wisconsin Details

The Individual Service Plan Wisconsin Form is a document used to track an individual's progress and services. The form can be used by case managers, counselors, therapists, or any other service provider. The form includes areas for service goals, objectives, methods of assessment, and more. It is important to keep track of an individual's progress to ensure they are making the desired progress. The Individual Service Plan Wisconsin Form can help do just that.

This quick report will help you determine the time it'll require you to fill out individual service plan wisconsin, how many pages it has, and some other unique details about the PDF.

QuestionAnswer
Form NameIndividual Service Plan Wisconsin
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other nameshow to fill in individual service plan examples wisconsin, ArrangementHSRS, F-20445, individual service plan template FormsPal

Form Preview Example

DEPARTMENT OF HEALTH SERVICESSTATE OF WISCONSIN

Division of Long Term Care

F-20445 (08/2008)

INDIVIDUAL SERVICE PLAN – MEDICAID WAIVERS

1 Waiver Program

 

 

 

 

 

 

 

 

 

 

 

 

 

1a Plan Type (Check ALL That Apply)

 

 

 

 

 

 

 

 

2 Medicaid ID Number

 

CIP II

COP-W

 

CIP 1A

CIP 1B

BIW

 

 

 

New

 

 

 

 

Six Month Review

 

 

 

 

 

COR

CLTS DD

 

CLTS MH

CLTS PD

 

 

 

 

 

 

 

Annual Recertification

CLTS Crisis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Update

 

 

 

 

CLTS Pilot

 

 

 

 

 

 

 

3

Individual’s Name

 

 

 

 

 

4

Address (street)

 

 

 

 

 

 

 

4a

City, State

 

 

 

 

 

 

 

 

4b

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5

Mailing Address (If Different)

 

 

 

6

Telephone

 

 

7 E-Mail

 

 

 

 

 

8 Service Plan

 

 

 

 

9 Functional Screen

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Development Date

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10

Cost Share Amount

 

11

Level of Care

12

Parental Fee (If

 

13

Personal Discretionary

14 [Reserved]

 

15 Start Up/One-

 

16

Waiver Cost/Day

 

 

 

 

 

 

 

 

Applicable)

 

 

 

 

Funds Available

 

 

 

 

 

 

Time Cost -Total

 

 

 

Total

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17

Prior Living Arrangement-

 

18

Prior Living Arrangement-Name/Type

 

 

19

Current Living Arrangement-

 

20 Current Living Arrangement-Name/Type

HSRS Code

 

 

 

 

 

 

 

 

 

 

HSRS Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21

Waiver Agency

 

 

 

 

 

22 Agency Telephone No.

 

23

Support & Service Coordinator/Care Manager

 

 

24 SSC/CM Telephone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(SSC/CM)

 

 

 

 

 

 

 

 

 

 

 

 

No./Ext.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

25

Mailing Address (Agency)

 

 

City

 

 

State

Zip

 

26

Mailing Address (SSC/CM)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

27

E-mail Address (Agency)

 

 

 

 

 

 

 

 

 

 

 

28

E-mail Address (SSC/CM)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

29

Name – Parent(s) or Guardian

 

 

 

 

 

 

 

 

 

 

 

30

Telephone No. (Home)

 

 

31 Telephone No. (Work)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

32

Mailing Address (Street/PO Box)

 

 

 

 

 

 

 

 

 

 

33

City

 

 

 

 

 

 

 

 

 

34

State

 

35 Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

36

E-mail Address

 

 

 

 

 

 

 

 

 

 

 

 

 

37

Telephone No. (Cell)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IN CASE OF EMERGENCY, NOTIFY:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

38

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

39

Telephone No. (Home)

 

 

40 Telephone No. (Work)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

41

Address

 

 

 

 

 

 

 

 

 

 

 

42 City

 

 

 

 

 

43 State

44

Zip

 

 

45 Relationship

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F-20445 Page 2

62 Service Code #

63Service Name

64Outcome No. (F- 20445A #5)

65 Service Provider Name Address and Telephone No. (E-mail, cell phone no., if known)

65a Start

Date

65b End Date

66 Unit Cost ($/hr; day)

67 Authorized Units of Service and Frequency (#/day or week or month)

68 Daily Cost

 

(total yearly ÷

69 Funding

365 days)

Source

F-20445 Page 3

70

I have been informed that I have a choice between an ICF-MR or nursing home (dependent on waiver type) and community services through a Medicaid Home and Community Waiver Program.

I have been informed of and understand my choices in the waiver programs, including approval or rejection of the services and providers listed on this service plan.

I have been informed of and understand my rights and responsibilities in the Medicaid Home and Community Waiver Programs.

I was informed verbally and in writing of my rights and responsibilities.

By my signature below I indicate I have chosen to accept community services through a Medicaid Home and Community Waiver Program.

SIGNATURE - Participant

Date Signed

SIGNATURE – Support and Service Coordinator/Care Manager

Date Signed

 

 

 

 

SIGNATURE – Guardian/Authorized Representative/Parent

Date Signed

SIGNATURE - Guardian/Authorized Representative/Parent

Date Signed

 

 

 

 

SIGNATURE - Witness

Date Signed

SIGNATURE – Witness

Date Signed

 

 

 

 

Distribution: DHS, County Care Manager/Support and Service Coordinator, Individual, Authorized Representative

 

F-20445 Page 3B

CIP II/COP-W CBRF Variance Request [Check () the type of variance requested)

A variance to the 20-bed CBRF size limitation for an individual that is elderly

A variance to allow waiver funding for an individual that is elderly to reside in a CBRF connected to a nursing home

By signing below, the Support and Service Coordinator / Care Manager attests to the following:

1.The environment is non-institutional and the facility operates in a manner than enhances resident dignity and independence, and

2.The facility is the preferred residence of the applicant/participant or his/her legal representative.

70

I have been informed that I have a choice between an ICF-MR or nursing home (dependent on waiver type) and community services through a Medicaid Home and Community Waiver Program.

I have been informed of and understand my choices in the waiver programs, including approval or rejection of the services and providers listed on this service plan.

I have been informed of and understand my rights and responsibilities in the Medicaid Home and Community Waiver Programs.

I was informed verbally and in writing of my rights and responsibilities.

By my signature below I indicate I have chosen to accept community services through a Medicaid Home and Community Waiver Program.

SIGNATURE - Participant

Date Signed

SIGNATURE – Support and Service Coordinator/Care Manager

Date Signed

 

 

 

 

SIGNATURE – Guardian/Authorized Representative/Parent

Date Signed

SIGNATURE - Guardian/Authorized Representative/Parent

Date Signed

 

 

 

 

SIGNATURE - Witness

Date Signed

SIGNATURE – Witness

Date Signed

 

 

 

 

Distribution: DHS, County Care Manager/Support and Service Coordinator, Individual, Authorized Representative

 

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