APPENDICES
,Listing of Appendices
Appendix A:
Introductory Person-Centered Plan Template
Complete Person-Centered Plan Template
Person-Centered Plan Update/Revision Template
Person-Centered Plan Update/Revision Signature Page Template
LME Consumer Admission and Discharge Form and Instructions
CAP-MR/DD Cost Summary
Appendix B:
Core Rules Self Study – Client Records Checklist
Appendix C:
MH/DD/SA Service Delivery Table
Appendix D:
Sample Forms and the CAP-MR/DD Residential Support and Home Support Grid
Instructions for Using the Sample Grid
Sample Grid Form
Sample Service Note A
Sample Service Note B
Sample Service Note C
Sample Service Note D
Sample Form for PSR Daily Note
CAP-MR/DD Residential Support and Home Support Grid
Appendix E:
Accessing Care: A Flow Chart for New Medicaid and New State Funded Consumers
Appendix F:
General Statute for Minor Consent
Appendix G:
Behavioral Health Prevention Education Services for Children and Adolescents in
Selective and Indicated Populations
Appendix H:
Glossary
, APPENDIX A
Introductory Person-Centered Plan Template
Complete Person-Centered Plan Template
Person-Centered Plan Update/Revision Template
Person-Centered Plan Update/Revision Signature Page Template
LME Consumer Admission and Discharge Form and Instructions
CAP-MR/DD Cost Summary
, ‘S INTRODUCTORY
PERSON-CENTERED DESCRIPTION/PLAN
Name: (Preferred Name): DOB: / / Medicaid ID: Record #:
Person’s Address: Telephone #:
(Street/mailing address) (Home) ( ) -
(City/State/Zip) (Work) ( ) -
Date of Plan: / / CAP Only: (Check the box that applies)
Supports Waiver
Supports Waiver – Self Direction
Comprehensive Waiver
ACTION PLAN
Long Range Outcome: (Ensure that this is an outcome desired by the individual, and not a goal belonging to others.)
Where am I now in relation to this outcome?
CHARACTERISTICS/OBSERVATION (List characteristics/observations based on preliminary knowledge):
Short Range Goal Support/Intervention Who will Provide Support/Service
to Reach Goal Support/Intervention/ & frequency
Service?
Target Date (Not Reviewed Date Status Code Justification for Continuation/Discontinuation of Goal
to exceed 12
REFER TO PCP MANUAL FOR ADDITIONAL INSTRUCTION
Appendix A
,Listing of Appendices
Appendix A:
Introductory Person-Centered Plan Template
Complete Person-Centered Plan Template
Person-Centered Plan Update/Revision Template
Person-Centered Plan Update/Revision Signature Page Template
LME Consumer Admission and Discharge Form and Instructions
CAP-MR/DD Cost Summary
Appendix B:
Core Rules Self Study – Client Records Checklist
Appendix C:
MH/DD/SA Service Delivery Table
Appendix D:
Sample Forms and the CAP-MR/DD Residential Support and Home Support Grid
Instructions for Using the Sample Grid
Sample Grid Form
Sample Service Note A
Sample Service Note B
Sample Service Note C
Sample Service Note D
Sample Form for PSR Daily Note
CAP-MR/DD Residential Support and Home Support Grid
Appendix E:
Accessing Care: A Flow Chart for New Medicaid and New State Funded Consumers
Appendix F:
General Statute for Minor Consent
Appendix G:
Behavioral Health Prevention Education Services for Children and Adolescents in
Selective and Indicated Populations
Appendix H:
Glossary
, APPENDIX A
Introductory Person-Centered Plan Template
Complete Person-Centered Plan Template
Person-Centered Plan Update/Revision Template
Person-Centered Plan Update/Revision Signature Page Template
LME Consumer Admission and Discharge Form and Instructions
CAP-MR/DD Cost Summary
, ‘S INTRODUCTORY
PERSON-CENTERED DESCRIPTION/PLAN
Name: (Preferred Name): DOB: / / Medicaid ID: Record #:
Person’s Address: Telephone #:
(Street/mailing address) (Home) ( ) -
(City/State/Zip) (Work) ( ) -
Date of Plan: / / CAP Only: (Check the box that applies)
Supports Waiver
Supports Waiver – Self Direction
Comprehensive Waiver
ACTION PLAN
Long Range Outcome: (Ensure that this is an outcome desired by the individual, and not a goal belonging to others.)
Where am I now in relation to this outcome?
CHARACTERISTICS/OBSERVATION (List characteristics/observations based on preliminary knowledge):
Short Range Goal Support/Intervention Who will Provide Support/Service
to Reach Goal Support/Intervention/ & frequency
Service?
Target Date (Not Reviewed Date Status Code Justification for Continuation/Discontinuation of Goal
to exceed 12
REFER TO PCP MANUAL FOR ADDITIONAL INSTRUCTION
Appendix A
