Qualified Intellectual Disabilities Professional (Qidp) Visit Form - Idaho

The Idaho Department of Health and Welfare has released this version of the "Qualified Intellectual Disabilities Professional (Qidp) Visit Form" on August 9, 2012.

This form may be used by all Idaho residents: download the printable PDF by clicking the link below and use it according to the applicable legal guidelines.

ADVERTISEMENT
DEPARTMENT OF HEALTH AND WELFARE
QUALIFIED INTELLECTUAL DISABILITIES PROFESSIONAL (QIDP) VISIT
Participant Name _____________________________________ Medicaid # _______________________
Address _____________________________________________ Phone ___________________________
QIDP Name (please print)________________________________________________________________
I. Progress toward identified goals:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
II. Change in developmental plan:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
III. Summary:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Plan has been discussed with provider?
Yes
No
Provider Name ________________________________________
Provider Name ________________________________________
QIDP’s next visit in ______days.
___________________________________________________
__________________________
QIDP Signature
Date
___________________________________________________
__________________________
Participant Signature
Date
QIDP Visit Form V1.0
Page 1 of 1
8/9/2012, sc
DEPARTMENT OF HEALTH AND WELFARE
QUALIFIED INTELLECTUAL DISABILITIES PROFESSIONAL (QIDP) VISIT
Participant Name _____________________________________ Medicaid # _______________________
Address _____________________________________________ Phone ___________________________
QIDP Name (please print)________________________________________________________________
I. Progress toward identified goals:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
II. Change in developmental plan:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
III. Summary:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Plan has been discussed with provider?
Yes
No
Provider Name ________________________________________
Provider Name ________________________________________
QIDP’s next visit in ______days.
___________________________________________________
__________________________
QIDP Signature
Date
___________________________________________________
__________________________
Participant Signature
Date
QIDP Visit Form V1.0
Page 1 of 1
8/9/2012, sc
ADVERTISEMENT