"Service Plan Signature Page" - Colorado

Service Plan Signature Page is a legal document that was released by the Colorado Department of Health Care Policy and Financing - a government authority operating within Colorado.

Form Details:

  • Released on November 1, 2020;
  • The latest edition currently provided by the Colorado Department of Health Care Policy and Financing;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Colorado Department of Health Care Policy and Financing.

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Service Plan Signature Page
Client Information (complete all sections that apply)
First Name:
Last Name:
DOB:
Medicaid ID:
Staffing Date:
Certification Start Date:
Certification End Date:
Service Plan Type:
Initial
CSR
Revision
Statement of Agreement
Client/Guardian indicates that they are in agreement with the information in the Service Plan and agrees to receive services accordingly.
OR
Client/Guardian acknowledges that they are choosing not to sign the Service Plan agreement. A Notice of Action will be provided as a result
of not signing the Service Plan.
Signatures
Client Signature
Date
Legal Guardian Signature
Date
☐ Court Appointed Guardian
Case Manager Signature
Date
Legal Guardian Signature
Date
☐ Court Appointed Guardian
Plan Participants
The following individuals participated in the development of this plan. This plan must be signed by all individuals and providers responsible for its
implementation.
Name
Title or Relationship
Signature
Date
Client must receive a copy of this completed signature page and a copy retained in case management agency files.
Service Plan Signature Page
November 2020
Page 1 of 2
Service Plan Signature Page
Client Information (complete all sections that apply)
First Name:
Last Name:
DOB:
Medicaid ID:
Staffing Date:
Certification Start Date:
Certification End Date:
Service Plan Type:
Initial
CSR
Revision
Statement of Agreement
Client/Guardian indicates that they are in agreement with the information in the Service Plan and agrees to receive services accordingly.
OR
Client/Guardian acknowledges that they are choosing not to sign the Service Plan agreement. A Notice of Action will be provided as a result
of not signing the Service Plan.
Signatures
Client Signature
Date
Legal Guardian Signature
Date
☐ Court Appointed Guardian
Case Manager Signature
Date
Legal Guardian Signature
Date
☐ Court Appointed Guardian
Plan Participants
The following individuals participated in the development of this plan. This plan must be signed by all individuals and providers responsible for its
implementation.
Name
Title or Relationship
Signature
Date
Client must receive a copy of this completed signature page and a copy retained in case management agency files.
Service Plan Signature Page
November 2020
Page 1 of 2
First Name:
Last Name:
DOB:
Medicaid ID:
Additional Plan Participants
This is a continued list of individuals who participated in the development of this plan. This plan must be signed by all individuals and providers responsible for
its implementation.
Name
Title or Relationship
Signature
Date
Client must receive a copy of this completed signature page and a copy retained in case management agency files.
Service Plan Signature Page
November 2020
Page 2 of 2
Page of 2