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Fill Out Your Individual Service Plan Wisconsin Template

The Individual Service Plan (ISP) Wisconsin form is a document used to outline the services and supports provided to individuals participating in Medicaid waiver programs. It details the individual's needs, preferences, and the resources available to them. This form ensures that participants are informed of their rights and choices regarding their care and services.

Fill Out Your Individual Service Plan Wisconsin Online

Fill Out Your Individual Service Plan Wisconsin Online

Structure

The Individual Service Plan (ISP) in Wisconsin serves as a crucial tool for individuals enrolled in Medicaid Waiver programs. This form captures essential details about the individual, including their name, address, and Medicaid ID, ensuring that all necessary information is readily available. It outlines the type of waiver program, whether it’s a new application or a recertification, and includes vital dates such as the current ISP date and the functional screen development date. Additionally, the form addresses the individual's living arrangements, both prior and current, which helps in assessing their needs effectively. Importantly, it also includes sections on service codes, provider information, and the costs associated with the services, ensuring transparency and clarity in the support being provided. Participants are informed of their rights and choices, emphasizing their ability to select services and providers that best meet their needs. This empowers individuals to take an active role in their care while ensuring that they are aware of their rights within the Medicaid system. Overall, the ISP is designed to facilitate a personalized approach to care, enabling individuals to receive the support they need in a manner that respects their preferences and rights.

Form Example

DEPARTMENT OF HEALTH SERVICESSTATE OF WISCONSIN

Division of Long Term Care

F-20445 (07/2014)

INDIVIDUAL SERVICE PLAN – MEDICAID WAIVERS

1 Waiver Program

1a Plan Type

1b Current ISP Date

2 Medicaid ID or MCI

CIP II

CIP II CRI.MFP

CIP II-DIV

COP-W

New

Recertification

Number (as applicable)

Six Month Review

CIP 1A

CIP 1B

CLTS

ISP Update

Individual’s Name

Address (street)

City, State, Zip Code

4b Date of Birth

Mailing Address (If Different)

Telephone

8 Initial Service Plan

9 Functional Screen

Development Date

Date

Cost Share Amount

Level of Care

12 Parental Fee (If

Personal Discretionary

14 [Reserved]

15 Start Up/One-

16 Waiver Cost/Day

Applicable)

Funds Available

Time Cost -Total

Total

Prior Living Arrangement-

Prior Living Arrangement-Name/Type

Current Living Arrangement-

20 Current Living Arrangement-Name/Type

HSRS Code (CLTS- N/A)

Waiver Agency

22 Agency Telephone

No.

Support & Service

Coordinator/Care Manager

24 SSC/CM Telephone

(SSC/CM)

No./Ext.

Mailing Address (Agency)

City

State

Zip

Mailing Address (SSC/CM)

E-mail Address (Agency)

E-mail Address (SSC/CM)

Name – Parent(s) or Guardian

Telephone No. (Home)

31 Telephone No. (Work)

Mailing Address (Street/PO Box)

City

State

35 Zip

E-mail Address

Telephone No. (Cell)

IN CASE OF EMERGENCY, NOTIFY:

Name

Telephone (Preferred/Primary No.)

Email Address

Address

42 City

State

Zip

45 Relationship

F-20445 Page 2

62 Service Code #

63 Service Name

64	65
Outcome No.	Service Provider Name Address and
(F-20445A #5)	Telephone No.
	(Email, cell phone no., if known)

65a

Start Date

65b

End Date

Unit Cost ($/hr; day)

Authorized Units of Service and Frequency

(#/day or week or month)

68	69
Daily Cost (total	Funding
yearly ÷ 365 days)	Source

70 PARTICIPANT INFORMED – R IGHTS AND CHOICE (Review REQUIRED at initial plan development and recertification.)

I have been informed that I have a RIGHT TO CHOOSE between a nursing home or ICF-IDD and community services through a Medicaid Home and Community Based Service Program.

I have been informed of my CHOICES in the waiver programs, including my right to CHOOSE the TYPE OF SERVICES I receive under my service plan.

I understand that I have CHOICES in the waiver programs, including my right to CHOOSE from available, qualified providers that will provide the services outlined in my plan.

I have been informed verbally and in writing of my rights and responsibilities in the Medicaid Waiver Programs and I understand these rights and responsibilities.

I have been informed verbally and in writing of my RIGHT TO REQUEST A HEARING should I disagree with decisions made about my ELIGIBILITY to participate in the HCBS program.

I have been informed verbally and in writing of my RIGHT TO REQUEST A HEARING should I disagree with decisions made that would DENY, REDUCE OR TERMINATE the services I receive.

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

71 UPDATE/REVIEW VERIIFICATION - APPLIES TO PLAN REVIEW OR ISP UPDATE ONLY

The SIX MONTH ISP Review was completed with the participant/guardian on the date below and there are no changes to the ISP at this time.

The SIX MONTH ISP Review was completed with the participant/guardian on the date below and agreed upon changes to the ISP are included herein.

The ISP was UPDATED on the date below to reflect changes (additions, increases or reductions) to planned services or providers or to units/frequency of service.

SIGNATURES: ISP Signature Requirements apply at the time of plan development, review and recertification.

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: Original – DHS; Copy - County Care Manager/Support and Service Coordinator; Copy – Individual; Copy - Authorized Representative

F-20445 Page 3B

CIP II/COP-W CBRF VARIANCE REQUEST [CHECK (√) THE TYPE OF VARIANCE REQUESTED) NOT APPLICABLE TO CIP 1A/B OR CLTS

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.

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: Original – DHS; Copy - County Care Manager/Support and Service Coordinator; Copy – Individual; Copy - Legal Representative

➤ PDF File

Document Specs

Fact Name	Details
Form Title	Individual Service Plan – Medicaid Waivers
Governing Law	Wisconsin Statutes, Chapter 46
Form Number	F-20445 (07/2014)
Review Frequency	Six-month review required for ongoing services
Participant Rights	Participants have the right to choose services and providers
Signature Requirements	Signatures needed from participant, coordinator, and guardian

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