Initial Transition Meeting Discussion Document Assessment Date: Plan Date: Plan Participants: Demographics and Services Individual Information Last Name First Name Middle Name DOB Street City State ID SSN Medicaid # Medicare # Guardian Information Guardian Last Name Guardian Name Guardianship Type Phone Street City State Agency Info Receiving Agency (Regional Office) POC (Service Coordinator) City Transferring Agency (Regional Office) POC (Service Coordinator) City Phone Regulatory Compliance To be completed within 30 days See Attached See Attached See Attached To be Completed within 30 Days Choice of Provider Annual Personal Plan ICF-MR of Care Health Inventory Nursing Review / Waiver Choice Services UR Approved Service Requested / Identified Provider Requested Start Date Authorized Date YES NO
Initial Transition Meeting Discussion Document Assessment Date: Plan Date: Plan Participants: Demographics and Services Individual Information Last Name First Name Middle Name DOB Street City State ID SSN Medicaid # Medicare # Guardian Information Guardian Last Name Guardian Name Guardianship Type Phone Street City State Agency Info Receiving Agency (Regional Office) POC (Service Coordinator) City Transferring Agency (Regional Office) POC (Service Coordinator) City Phone Regulatory Compliance To be completed within 30 days See Attached See Attached See Attached To be Completed within 30 Days Annual Personal Plan Choice of Provider / Waiver Choice ICF-MR of Care Health Inventory Nursing Review Services Service Requested / Identified Provider UR Approved Requested Start Date Authorized Date YES NO
initialtransitionmeetingguide.docx