Name Physical or Mental Health Specialist or Clinic Specialty Telephone Number – Name Other Physical or Mental Health Specialist or Clinic Specialty Telephone Number – Name Other Physical or Mental Health Specialist or Clinic Specialty Telephone Number – B. Preferred Hospital/ Clinic Note: Use of a hospital may be dictated by insurance company / plan Name Address (Street, City, State, Zip Code) Telephone Number Name Address (Street, City, State, Zip Code) Telephone Number C. Health Insurance Coverage Medicaid Assistance (MA) Card Yes No Has the out-of-home care provider been given If no, describe how and when it will be provided. the child's MA card (regular or temporary)? Other Health Insurance Provider Name Telephone Number Insurance Policy Number Insurance Policy Number D. Medical Diagnoses Yes No The child has chronic physical, mental or Specify: emotional needs. Yes No The has had a hospitalization, surgery, Specify: emergency medical need, or significant illness in the last six months. Yes No The child has identified special health care Specify: needs. E. Medications Yes No The child is currently prescribed medication(s). Specify: Name Medication Dosage / Frequency – Reason for Medication Name Prescribing Physician – Length Prescribed Address Prescribing Physician – Yes No Is this a psychotropic medication? Yes No Has this medication been provided to the Specify: care provider? Name Medication Dosage / Frequency – Reason for Medication Name Prescribing Physician – Length Prescribed Address Prescribing Physician – Yes No Is this a psychotropic medication? Yes No Specify: Has this medication been provided to the care provider? Name Medication Dosage / Frequency –
Name – Physical or Mental Health Specialist or Clinic Specialty Telephone Number Name – Other Physical or Mental Health Specialist or Clinic Specialty Telephone Number Name – Other Physical or Mental Health Specialist or Clinic Specialty Telephone Number B. Preferred Hospital/ Clinic Note: Use of a hospital may be dictated by insurance company / plan Name Address (Street, City, State, Zip Code) Telephone Number Name Address (Street, City, State, Zip Code) Telephone Number C. Health Insurance Coverage Medicaid Assistance (MA) Card Yes No Has the out-of-home care provider been given the child's MA card (regular or temporary)? If no, describe how and when it will be provided. Other Health Insurance Provider Name Telephone Number Insurance Policy Number Insurance Policy Number D. Medical Diagnoses Yes No The child has chronic physical, mental or emotional needs. Specify: Yes No The has had a hospitalization, surgery, emergency medical need, or significant illness in the last six months. Specify: Yes No The child has identified special health care needs. Specify: E. Medications Yes No The child is currently prescribed medication(s). Specify: Name – Medication Dosage / Frequency Reason for Medication Name – Prescribing Physician Length Prescribed Address – Prescribing Physician Yes No Is this a psychotropic medication? Yes No Has this medication been provided to the care provider? Specify: Name – Medication Dosage / Frequency Reason for Medication Name – Prescribing Physician Length Prescribed Address – Prescribing Physician Yes No Is this a psychotropic medication? Yes No Has this medication been provided to the care provider? Specify: Name – Medication Dosage / Frequency