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In accordance with Person Centered Service Planning Guidelines
Summary Page
Authorization Period________________ Date Issued________________
If you have a question or a problem regarding your services, call your care manager below,
____________ [ Care Manager Name ] ____________ at (xxx) xxx-xxxx
Description of Services
Use this area to identify current services received by the enrollee. [Duplicate boxes below as needed].
Name of Service
Scope/Description of Service
Unit and Frequency of Service Provider
Duration/Authorization Period Contact Information
Assessment Identifying Need Authorizing Entity
Desired Outcome/Goals
Name of Service
Scope/Description of Service
Unit and Frequency of Service Provider
Duration/Authorization Period Contact Information
Assessment Identifying Need Authorizing Entity
Desired Outcome/Goals
Name of Service
Scope/Description of Service
Unit and Frequency of Service Provider
Duration/Authorization Period Contact Information
Assessment Identifying Need Authorizing Entity
Desired Outcome/Goals
Informal Supports
Identify unpaid supports and their relationship to the enrollee. [Duplicate boxes below as needed.]
Enrollee Name Date of Birth
Address
Phone Number Preferred Language
Email Address
Name
Relationship/Title Contact Information
Service(s) Provided/
Support Role
Unit and Frequency of Service
In accordance with Person Centered Service Planning Guidelines
Enrollee Information
Residential Setting and Supports
Use this section to confirm that the individuals residential setting meets the HCBS settings rule.
Primary Care Manager Secondary Care Manager
Organization Organization
Primary Care Provider (PCP)
PCP Contact Information
Medicaid/CIN #
Primary Insurance Agency Secondary Insurance Agency
Enrollee ID Enrollee ID
Is the residential address provided a community-based setting? Yes โ No โ
Enrollee chose where they live now. Yes โ No โ
Enrollee can participate in the activities they like inside and outside of their home. Yes โ No โ
Enrollee can go to work if/ when they want to. Yes โ No โ
Enrollee can go to school if/ when they want or need to. Yes โ No โ
Enrollee can visit friends and family if/ when they want to. Yes โ No โ
Enrollee can enjoy food and snacks that they like whenever they want to. Yes โ No โ
Enrollee can easily move around their home and other places where services are received. Yes โ No โ
Use the space provided below for additional comments if the answer to any of the questions above is โNoโ.
In accordance with Person Centered Service Planning Guidelines
Strengths, Preferences, Unmet Service Needs and Goals
Use this section to describe the strengths, preferences, unmet service needs and goals/desired outcomes (both likes and
dislikes) of the enrollee.
Strengths:
Ask the enrollee about the things he or she is good at. Provide responses as well as other known strengths of the enrollee in the
space below.
Preferences:
Ask the enrollee about the things he or she likes or strongly dislikes. Provide responses as well as other known preferences of the
enrollee in the space below. Include preferences for delivery of services.
In accordance with Person Centered Service Planning Guidelines
Unmet Service Needs
Identify below the services the individual needs. [Duplicate boxes below as needed].
Goals/Desired Outcomes:
Use the space below to identify the health care and social goals/desired outcomes of the enrollee. Goals may be long-term or
short-term with measurable outcomes. Where applicable, indicate which unmet service need the goal ties into. Include strategies to
achieve desired outcome. [Add boxes for additional outcomes as needed].
Goal/ Desired
Outcome
Goal/ Desired
Outcome
Service Need Assessment/Date Identified
Justification for service
Reason Need is Unmet
Plan to Address Need
Service Need Assessment/Date Identified
Justification for service
Reason Need is Unmet
Plan to Address Need
In accordance with Person Centered Service Planning Guidelines
Population Specific Requirements
Include as needed.
Self-Directed Services:
Fill out this box for enrollees getting Self-Directed Services under 42 CFR 441 Sub-parts G, K, and M. If this information is
documented in another place, attach attestation to this POC. [Duplicate service description portion for each self-directed service].
โ I, ______________________, choose to self-direct some or all of my services.
โ ______________________, may also act on my behalf to self-direct some or all of my services.
This means that I have the right to recruit, hire, fire, supervise, and manage my own staff. Alone, or with the help of my supports, I
can choose the duties, schedules, and training requirements of my staff. This also includes the right to evaluate staff, decide their
rate of pay, and review/approve payment requests. I will follow all laws and regulations when exercising these rights and
responsibilities. The services I choose to self-direction are:
Service:
Method of Self-Direction:
Risk Management Techniques:
Process for Transitioning out of Self-Direction:
Financial Management Supports:
Specific Employer Authority Information:
Specific Budget Authority Information (see 42 CFR 441.740(d)):
In accordance with Person Centered Service Planning Guidelines
Residential Modifications:
Fill out these boxes for special populations receiving services under 42 CFR 441 Subparts G, K, and M. Use the first box to
identify modifications to a residential setting. Such modifications described here may relate to a change in: status of written,
legal agreements to live in the current setting; privacy; lockable entrance doors with only appropriate staff keeping keys;
choice of roommate(s); freedom to furnish/decorate within legal agreements; control of schedules, activities, and food
choices; or the ability to receive visitors of the enrolleeโs choosing at any time. [Duplicate modifications box if needed for
multiple modifications].
โ I, ______________________, understand the information below and agree to the use of this(/these) modification(s)
required to address my assessed risk(s) and need(s). I know that I can change my mind and will tell my Care
Manager if I do.
Modification:
Specific Individualized Assessed Need:
Positive Interventions and Supports used Before this Modification:
Diagnosis/Condition Related to the Modification:
Method for Collection and Review of Data for Effectiveness:
Timeframes/Limits for Review and Determination of Need for Modification:
Assurance that the Modification Will Cause No Harm:
