Form 4207 constitutes the required final pages of the Individualized Family Service Plan (IFSP) used to record the ECI services planned for the child. Page 1 is also used to fax information to the Health Passport for children in foster care. The information contained on page 1 of the form will be included in the Health Passport.
Acronyms and Definitions
LPHA—Licensed Practitioner of the Healing Arts
SST—specialized skills training
Copies and Distribution
Provide a copy to the parent.
See Special Instructions.
Unless a longer period is required by state or federal law, the contractor must retain records for five years after the child has been dismissed from services.
- Child’s name—Enter the name of the eligible ECI child.
- Client ID—Enter either a local ID or the TKIDS case ID number.
- ECI program—Enter the name of your agency.
Provide the following information under the Service Information section:
- Service—Enter the type of ECI services that the interdisciplinary team determines the child needs. Use the abbreviations in the Services key on page 1. If SST is planned, the IFSP must also document a planned service (minimum 1 X 6 months) by a licensed practitioner of the healing arts.
- Discipline of Provider—Enter the discipline of the provider who will provide the planned service. For case management, the name of the service coordinator must be entered.
- Expected Frequency—Enter the planned frequency of the service (how often the service will be provided, such as number of times “per week” or “per month”).
On the first row, for CM, the field is prefilled “Ongoing.”
- Expected Intensity—Enter the intensity (amount of time of each service visit) that is planned.
On the first row, for CM, the field is prefilled “As Needed.”
- Total Authorized Visits—Enter the total number of planned visits (expected frequency) for the period of the IFSP, taking into account the projected start and end date for each service.
Example: 4 X month for 12 months is 48 Total Authorized Visits.
On the first row, for CM, the field is prefilled “Not Applicable.”
- Location—Select a box, or boxes, to identify the location where each service will be provided.
- There are three choices for location. Refer to Settings in Appendix A of the TKIDS manual for definitions. If “other” is selected, identify the specific setting according to those definitions.
- Provide an explanation at the bottom of page 1 of the form if “other” is selected and the services are not provided in the child’s natural environment.
- Method—Select a box for individual or group for each service. The interdisciplinary team may plan group services only when individual services are also planned on the IFSP.
On the first row, for CM, the field is prefilled “Not Applicable.”
- Start Date—Enter the projected start date(s) for each service.
- End Date—Enter the projected end date(s) for each service (an end date cannot be more than one year from the initial or annual IFSP sign date).
- Services Designation—Enter the services designation in the box.
Services Designation Key
PP—Program Provided: Service is provided by personnel employed or subcontracted by the ECI program.
PC—Parent Choice: Service is provided by an outside provider of the parent’s choice. Family declined the ECI program’s provider and is therefore responsible for finding and arranging service delivery and payment.
PA—Program Arranged: Service is delivered by a provider who is neither an employee nor subcontractor of the ECI program. However, the provider is trained in Part C service delivery, participates on the IFSP team and supplies progress notes of their service delivery to the program.
NP—Not a Part C Service: Service is delivered by a provider who is not an employee or subcontractor of the ECI program. The outside provider
- is NOT trained in Part C service delivery, or
- is NOT part of the IFSP team, or
- does NOT provide progress notes of their service delivery.
- Name of Routine Caregiver—If services won’t be provided in the presence of the parent, document the full name of each person or entity (e.g., name of daycare) who will participate in ECI services with the child. If the routine caregiver changes, document the name of the new caregiver and attach to the IFSP.
- Justification for Providing Service with the Routine Caregiver—Document how the child will benefit from services delivered with the routine caregiver.
- Justification for Co-visits—Describe how the child and family will receive greater benefit from services being provided at the same time.
- If the parent has chosen a service provider outside of ECI (Parent Choice (PC), he or she must initial the form to indicate his or her understanding of this statement: “Indicating Part Choice (PC) in the Designation box on the services pages indicates the family is responsible for finding and arranging service delivery and payment. __.(parent initials)”
Payment Arrangements—Discuss the payment arrangement for services on the IFSP and select the appropriate boxes (select all that apply):
- ECI—Select this box for every child.
- Family Fees—Select this box for families who have a monthly maximum charge greater than zero.
- Public/Private Insurance—Select this box for families who have Medicaid, CHIP, TRICARE, or private insurance that will pay for services.
- Assistive Technology—Select the appropriate box.
Provide the following information under the Signatures section:
Before obtaining the parent signature, review the entire IFSP and discuss the rights statements with the family.
- Family Comments—Offer the family members an opportunity to write any comments they may want to add to the document. If there are any negative comments, your program director must be informed.
- Parent Signature and Date—After the rights statements are reviewed and the parent has been offered the opportunity to comment, have the parent sign and date the document. The parent’s signature does not indicate agreement with the IFSP. It does signify consent for services and provides authorization for services to be provided with the routine caregiver (if applicable).
- Complete the signature table with the following information:
- ECI Team Member Signature—(Refer to 40 TAC Sections 108.1009, 108.1011, and 108.1013.) Each interdisciplinary team member signs the document, including team members who participated in the meeting and any who review the document at a later time. The signatures of the ECI Team members indicate agreement with the plan and, if applicable, commitment for providing the services as planned on the IFSP Services Page. An LPHA for the team recommends the services on the IFSP services page by signing in the box with LPHA Signature above this statement: “The signature of the LPHA indicates that he or she recommends the services on the IFSP (including OT, PT, Speech and Language Therapy, and SST) as reasonable and necessary.
- Other Team Member Signatures (for example, grandparent, child care teacher)—Each person will sign and indicate that he or she was present at the meeting.
- Discipline—Enter the discipline of each interdisciplinary team member.
- Date—Enter the date the individual signs the IFSP.
- Present—Select the box if the person was present at the IFSP meeting.
- Reviewed—Select the box if the person reviewed the IFSP but was not present at the meeting.
- Page 1a—Use this page if you need additional space for planned services. Follow the instructions above in 4 through 13.
- Page 2a—Use this page if you need additional space for signatures. Follow the instructions above in 21.
- Use the cover sheet provided by Superior Health Plan when you send page 1 of this form. Include the information requested on the Health Passport Cover Sheet. You can download the cover sheet from the Superior Health Plan website at www.superiorhealthplan.com (link is external) under Health Passport Forms.
- The fax number for entry of page 1 of Form 4207 is 1-866-274-5952.
- Complete page 2 of this form as a part of the IFSP document, but do not send it to the Health Passport.