Attachment 6

Chester County Intermediate Unit

HOME AND COMMUNITY SERVICES

PLAN OF CARE SUMMARY

MEMBER INFORMATION
/
CONTACT INFORMATION
Name /
BHRSCA Provider
DOB
/ Age / Name of Provider Contact
MA# / Provider Contact Phone #
Child’s County of HC Eligibility: / Prescriber Name
DIAGNOSIS / Prescriber Phone #
Axis I / / Code / Date of Evaluation
Axis I / / Code / CCBH Care Manager
Axis I / Code / County Case Mgr. Signature
Axis II / Code /
Primary PHMCO
Axis III /
Date Provider Informed PCP
Axis IV /
CCBH Eligible according to EVS
/ Yes / Date EVS checked
Axis IV / POC Begin Date / Amended POC Begin Date
Axis V / Current GAF: / Past GAF: / POC End Date / Amended POC End Date
BHRSCA SERVICE PLAN
Note: 1 month = 4.5 weeks / SERVICE SYSTEM/ PROVIDER / RESPONSIBLE PERSON / FREQUENCY: PRESCRIBED HOURS PER WEEK / LENGTH OF SERVICE: TOTAL # OF WEEKS (typically 18 weeks) / TOTAL UNITS: MAX HRS PER WEEK X UNITS PER HR X TOTAL # OF WEEKS
BSC/PhD 15 min unit H0032 HP
BSC/MA 15 min unit H0032 HO
MT 15 min unit H2019
MMTM 15 min unit H2019-HT
TSS 15 min unit H2021
CM 15 min unit T1016-EP
LD PSY RE-EVAL 908201-EP
If BSC or MT (MT not for Chester County) is Requested Please Complete the Following: (ASD Only)
Was an FBA Completed? ¨ Yes ¨ No Is the treatment plan based on the findings of the FBA? ¨ Yes ¨ No

Member Name:___ MA# __ POC Time Period:___

ADDITIONAL SERVICES AND SERVICE COORDINATION
ADDITIONAL SERVICE
/
SERVICE SYSTEM/
PROVIDER /
RESPONSIBLE
PERSON /
PHONE NUMBER
/
COMMENTS
Case Management Services
¨ Administrative – ACM
¨ ICM ¨ RC
¨ Targeted/Blended CM
¨ ISC (MR) ¨ JPT /
Outpatient Therapy
/ /
Partial Hospitalization
Medication Management
/ /
Drug and Alcohol Services / /
Mental Retardation Services
/ /
Children and Youth
¨ Voluntary Involvement
¨ Adjudicated Dependent /
Juvenile Justice
¨ Adjudicated Delinquent
¨ Consent Decree / /
School District Name:
______
¨ Reg Ed ¨ Sp Ed ¨ Other / Name of School: /
School Contact:
/ Mailing Address:
Primary Care Physician / /
Community Resources /
Mobile Crisis Services
Comments/Clarifications:

RMT 12/10 HCCH, HCCK