Client Chart Index

Rev. 2008

Section 1:

• Chart Index
• Utilization Review Forms

Section 2:

• Face Sheet with emergency information
• Safety Alerts Plan and updates including medications and medical alerts

Section 3:

• Screening, Referral and Enrollment Information:
  • Parent/Guardian Request for Screening
  • Screening forms
  • Level of Care and Level of Care Recertifications
  • Screening Results Letter to Family from LGU
  • Application for Waiver Participation/Freedom of Choice form
  • Choice of Waiver Provider Verification
  • OMH Notice of Decision (Waiver Acceptance or Termination) with enrollment or termination date

Section 4:

• Including the following labeled subsections:
  1. Service Plans with corresponding CANS, Service Plan Budget and any Treatment Provider comments
  2. Flex Funds Tracking forms and receipts

Section 5:

• Progress Notes divided into the following subsections:
  1. ICC
  2. IIH
  3. CR
  4. SBS
  5. FSS
  6. RS

Section 6:

• Releases of Information
1. Permissions
2. Statements of understanding

Section 7:

1. Medicaid: Application/Information/Medicaid Correspondence

Section 8:

• Assessments (Psychological, Educational, etc.)

Section 9:

1. Correspondence/Miscellaneous

Section 10:

1. Discharge Plans; After-Care Follow-Up; Disenrollment Progress Note

Comments or questions about the information on this page can be directed to the Home and Community Based Waiver Program.