Form 8665-ID, Individual Data

Instructions for Opening a Form

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Documents

Effective Date: 9/2013

Instructions

Updated: 9/2013

Purpose

To develop the Individual Data portion of the Person-Directed Plan (PDP) for the Home and Community-based Services (HCS) Program and update, as needed. Person-directed planning is a process that empowers the individual and the legally authorized representative (LAR), on the individual’s behalf, to direct the development of a plan of supports and services that meets the individual’s personal outcomes.

Introduction

The service coordinator (SC) at the local authority (LA), using the discovery process as the basis for collecting information, develops the Individual Data portion of the PDP with the individual/LAR and others, as requested by the individual/LAR. This portion of the PDP is completed upon enrollment and maintained with the individual’s record. The Individual Data sheet is to be updated only when the individual’s information changes. It is not necessary to submit a copy of the Individual Data sheet to the provider every time the PDP is updated, unless the information on the Individual Data sheet has changed. The provider will receive a copy of the Individual Data sheet when the individual is enrolled, when the information on the Individual Data sheet is updated and when the individual is transferred to a new provider.

Procedure

The SC completes the form, gathering the information from appropriate sources.

Detailed Instructions

Name of Individual – Enter the individual’s full name.

CARE ID – Enter the Client Assignment and Registration (CARE) System number for the individual.

Date of Birth – Enter the date the individual was born.

Permanency Plan Required – Check the Yes box if the individual is under 22 years of age and will be or is residing in an HCS group home receiving Residential Support Services or Supervised Living. Check the No box for all others.

Local Case No. – Enter the individual's LA case number.

Social Security No. – Enter the individual’s Social Security number. (This is not a required field if the individual's Medicaid number is included on this form.)

ICAP Date/LON – Enter the date the Inventory for Client and Agency Planning (ICAP) was completed and the level of need (LON), as documented for the intellectual disability/related conditions (ID/RC).

Medicaid No. – Enter the individual’s Medicaid number. (If no Medicaid number is available, the individual's Social Security number must be included in the space provided.)

Medicaid Type – Enter the individual’s Medicaid type. For HCS, the Medicaid codes must be (R), the Medicaid type can be 01, 03, 07, 08, 09, 10, 12, 13, 14, 15, 18, 19, 21, 22, 29, 37, 44, 47, 48, 51, 61, 87 or 88.

Medicare No. – Enter the individual’s Medicare number, if applicable.

Medicare Type – Enter the individual’s Medicare type, if applicable.

If not currently receiving Medicaid, has a Medicaid application been filed? – If the individual does not have an active Medicaid status at the time of enrollment, a Medicaid application must be filed to determine financial eligibility for the HCS program. Mark the Yes or No box to indicate whether an application has been filed.

Medicaid Application Date – If the Yes box is marked, enter the date the application was filed.

Private Insurance – If the individual has coverage through a private insurance company, enter the name of the insurance company. If the individual does not have coverage through a private insurance company, enter N/A.

Emergency Contact Name and Telephone No. – Enter the name and telephone number of the person who has been identified by the individual/LAR as someone to contact in the case of an emergency. This may be the same person who is identified on the PDP as the primary correspondent.

Primary Correspondent (if different from Emergency Contact) – Enter the name of the primary correspondent, if different from the name of the emergency contact above.

Telephone No. – Enter the phone number of the person identified as the primary correspondent, if different from the emergency contact.

Guardian – Check the Yes or No box to indicate if the individual has a court appointed guardian.

Guardianship Current – If Yes is selected in the Guardian section, check the Yes or No box as it applies to the status of the guardianship.

Sex – Check the Male or Female box for the individual’s gender.

Marital Status – Check the appropriate box to indicate the current marital status of the individual.

Language – Check the appropriate box to indicate the primary language the individual uses to communicate. If Other is checked, enter the individual's primary language.

Reads English – Check the Yes or No box to indicate whether the individual is able to read and comprehend the English language.

Understands English – Check the Yes or No box to indicate if the individual understand the English language when spoken to.

Race/Ethnicity – Check the appropriate box to indicate the individual’s ethnicity. If Other is checked, enter the individual’s race/ethnicity.

Housing Assistance – Check the appropriate box to indicate if the individual currently has access to, or an application for, one of the government programs for housing assistance. If the individual does not have access to, or an application on file for one of these, check the N/A box.

Living Arrangement prior to enrollment – Check the appropriate box to indicate the individual’s living arrangement prior to enrolling into the HCS program. If Other is checked, enter the individual's living arrangement.

Legal Status* – Check the appropriate box to indicate the current legal status of the individual.

Communication* – Check the appropriate box to indicate the type of communication that is used most often by the individual to interact with others. Multiple boxes may be checked, if applicable. If the Other box is selected, include a brief description of the type of communication the individual uses to communicate with others.

Ambulation* – Check the appropriate box to indicate the individual’s ability to move from one area to another. If assistance is required, include a brief description of what kind of assistance is needed.

Community/Home Safety* – Check the appropriate box to indicate the individual’s ability to safely navigate his or her community and/or home independently.

Check any needs that apply* – Check all appropriate boxes as they pertain to the individual’s specific needs.

Check adaptive aids that apply* – Check all appropriate boxes as they pertain to the individual’s use of adaptive aids.

*Additional information may be needed in the PDP if this box is checked. This subject may require additional information in the PDP so the service provider has adequate detail about the individual’s needs as they relate to the services and supports.

Completed or updated on – Enter the date the form is completed or updated.