Form 6517 "Individual Program Plan (Ipp) Service Review" - Texas

What Is Form 6517?

This is a legal form that was released by the Texas Health and Human Services - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2020;
  • The latest edition provided by the Texas Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 6517 by clicking the link below or browse more documents and templates provided by the Texas Health and Human Services.

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Download Form 6517 "Individual Program Plan (Ipp) Service Review" - Texas

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Form 6517
September 2020-E
Deaf Blind with Multiple Disabilities
Individual Program Plan (IPP) Service Review
Name of Individual
Medicaid No.
Review Date
Next Review Date
DBMD Program Provider
DBMD Vendor Number
Financial Management Services Agency (FMSA)
FMSA Vendor Number
5A – Dental Services
Is this service authorized on the IPC?
Yes
No
If yes, number of authorized units:
1. Was this service category delivered in accordance with IPP/IPC? .........................................................................................
Yes
No
2. Is this service meeting the individual’s needs? .......................................................................................................................
Yes
No
3. Status of services provided:
Follow-up:
5B – Dental Sedation
Is this service authorized on the IPC?
Yes
No
If yes, number of authorized units:
1. Was this service category delivered in accordance with IPP/IPC? .........................................................................................
Yes
No
2. Is this service meeting the individual’s needs? .......................................................................................................................
Yes
No
3. Status of services provided:
Follow-up:
7 – Occupational Therapy
Is this service authorized on the IPC?
Yes
No
If yes, number of authorized units:
1. Was this service category delivered in accordance with IPP/IPC? .........................................................................................
Yes
No
2. Is this service meeting the individual’s needs? .......................................................................................................................
Yes
No
3. Document the progress on each service, goal or outcome as indicated on the IPP:
Follow-up:
Form 6517
September 2020-E
Deaf Blind with Multiple Disabilities
Individual Program Plan (IPP) Service Review
Name of Individual
Medicaid No.
Review Date
Next Review Date
DBMD Program Provider
DBMD Vendor Number
Financial Management Services Agency (FMSA)
FMSA Vendor Number
5A – Dental Services
Is this service authorized on the IPC?
Yes
No
If yes, number of authorized units:
1. Was this service category delivered in accordance with IPP/IPC? .........................................................................................
Yes
No
2. Is this service meeting the individual’s needs? .......................................................................................................................
Yes
No
3. Status of services provided:
Follow-up:
5B – Dental Sedation
Is this service authorized on the IPC?
Yes
No
If yes, number of authorized units:
1. Was this service category delivered in accordance with IPP/IPC? .........................................................................................
Yes
No
2. Is this service meeting the individual’s needs? .......................................................................................................................
Yes
No
3. Status of services provided:
Follow-up:
7 – Occupational Therapy
Is this service authorized on the IPC?
Yes
No
If yes, number of authorized units:
1. Was this service category delivered in accordance with IPP/IPC? .........................................................................................
Yes
No
2. Is this service meeting the individual’s needs? .......................................................................................................................
Yes
No
3. Document the progress on each service, goal or outcome as indicated on the IPP:
Follow-up:
Form 6517
Name of Individual
Medicaid No.
Review Date
Page 2 / 09-2020-E
8 – Physical Therapy
Is this service authorized on the IPC?
Yes
No
If yes, number of authorized units:
1. Was this service category delivered in accordance with IPP/IPC? .........................................................................................
Yes
No
2. Is this service meeting the individual’s needs? .......................................................................................................................
Yes
No
3. Document the progress on each service, goal or outcome as indicated on the IPP:
Follow-up:
9 – Speech, Hearing and Language Therapy
Is this service authorized on the IPC?
Yes
No If yes, number of authorized units:
1. Was this service category delivered in accordance with IPP/IPC? .........................................................................................
Yes
No
2. Is this service meeting the individual’s needs? .......................................................................................................................
Yes
No
3. Document the progress on each service, goal or outcome as indicated on the IPP:
Follow-up:
10 – Day Habilitation
Is this service authorized on the IPC?
Yes
No
If yes, number of authorized units:
1. Was this service category delivered in accordance with IPP/IPC? .........................................................................................
Yes
No
2. Is this service meeting the individual’s needs? .......................................................................................................................
Yes
No
3. Status of services provided:
Follow-up:
Form 6517
Name of Individual
Medicaid No.
Review Date
Page 3 / 09-2020-E
10CFC – Community First Choice (CFC) – Personal Assistance Services (PAS) Habilitation
Is this service authorized on the IPC?
Yes
No
If yes, number of authorized units:
1. Was this service category delivered in accordance with IPP/IPC? ...........................................................................................
Yes
No
2. Is this service meeting the individual’s needs? .........................................................................................................................
Yes
No
3. Did the Service Planning Team (SPT) identify a need for a backup plan? ...............................................................................
Yes
No
4. Did SPT create a backup plan for this service? ........................................................................................................................
Yes
No
5. Was backup plan implemented?................................................................................................................................................
Yes
No
6. Did backup plan meet the individual’s needs?...........................................................................................................................
Yes
No
7. Status of services provided:
Follow-up:
Document the progress on each service, goal or outcome as indicated on the IPP:
Follow-up:
11 – Respite (In-Home)
Is this service authorized on the IPC?
Yes
No
If yes, number of authorized units:
1. Was this service category delivered in accordance with IPP/IPC? .........................................................................................
Yes
No
2. Is this service meeting the individual’s needs? .......................................................................................................................
Yes
No
3. Status of services provided:
Follow-up:
11A – Respite (Out-of-Home)
Is this service authorized on the IPC?
Yes
No
If yes, number of authorized units:
1. Was this service category delivered in accordance with IPP/IPC? .........................................................................................
Yes
No
2. Is this service meeting the individual’s needs? .......................................................................................................................
Yes
No
3. Status of services provided:
Follow-up:
Form 6517
Name of Individual
Medicaid No.
Review Date
Page 4 / 09-2020-E
12 – Case Management
Is this service authorized on the IPC?
Yes
No
If yes, number of authorized units:
1. Was this service category delivered in accordance with IPP/IPC? .........................................................................................
Yes
No
2. Is this service meeting the individual’s needs? .......................................................................................................................
Yes
No
3. Status of services provided:
Follow-up:
13A – LVN Nursing Services
Is this service authorized on the IPC?
Yes
No
If yes, number of authorized units:
1. Was this service category delivered in accordance with IPP/IPC? ...........................................................................................
Yes
No
2. Is this service meeting the individual’s needs? .........................................................................................................................
Yes
No
3. Did the SPT identify a need for a backup plan? .......................................................................................................................
Yes
No
4. Did SPT create a backup plan for this service? ........................................................................................................................
Yes
No
5. Was backup plan implemented?................................................................................................................................................
Yes
No
6. Did backup plan meet the individual’s needs?...........................................................................................................................
Yes
No
7. Document the progress on each service, goal or outcome as indicated on the IPP:
Follow-up:
13B – RN Nursing Services
Is this service authorized on the IPC?
Yes
No
If yes, number of authorized units:
1. Was this service category delivered in accordance with IPP/IPC? ...........................................................................................
Yes
No
2. Is this service meeting the individual’s needs? .........................................................................................................................
Yes
No
3. Did the SPT identify a need for a backup plan? .......................................................................................................................
Yes
No
4. Did SPT create a backup plan for this service? ........................................................................................................................
Yes
No
5. Was backup plan implemented?................................................................................................................................................
Yes
No
6. Did backup plan meet the individual’s needs?...........................................................................................................................
Yes
No
7. Document the progress on each service, goal or outcome as indicated on the IPP:
Follow-up:
Form 6517
Name of Individual
Medicaid No.
Review Date
Page 5 / 09-2020-E
13C – RN Specialized Nursing
Is this service authorized on the IPC?
Yes
No
If yes, number of authorized units:
1. Was this service category delivered in accordance with IPP/IPC? ...........................................................................................
Yes
No
2. Is this service meeting the individual’s needs? .........................................................................................................................
Yes
No
3. Did the SPT identify a need for a backup plan? .......................................................................................................................
Yes
No
4. Did SPT create a backup plan for this service? ........................................................................................................................
Yes
No
5. Was backup plan implemented?................................................................................................................................................
Yes
No
6. Did backup plan meet the individual’s needs?...........................................................................................................................
Yes
No
7. Document the progress on each service, goal or outcome as indicated on the IPP:
Follow-up:
13D – LVN Specialized Nursing
Is this service authorized on the IPC?
Yes
No
If yes, number of authorized units:
1. Was this service category delivered in accordance with IPP/IPC? ...........................................................................................
Yes
No
2. Is this service meeting the individual’s needs? .........................................................................................................................
Yes
No
3. Did the SPT identify a need for a backup plan? .......................................................................................................................
Yes
No
4. Did SPT create a backup plan for this service? ........................................................................................................................
Yes
No
5. Was backup plan implemented?................................................................................................................................................
Yes
No
6. Did backup plan meet the individual’s needs?...........................................................................................................................
Yes
No
7. Document the progress on each service, goal or outcome as indicated on the IPP:
Follow-up:
15 – Adaptive Aids
Is this service authorized on the IPC?
Yes
No
If yes, number of authorized units:
1. Specifications obtained:
Yes
No
If no, explain:
2. Was this service category delivered in accordance with IPP/IPC? .........................................................................................
Yes
No
3. Is this service meeting the individual’s needs? .......................................................................................................................
Yes
No
4. List each adaptive aid authorized on the IPC and the status of each:
Follow-up:
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