* Must be identified on the Service Plan Service Plan Date:__________________ Progress Notes School Based Targeted Case Management – Unit is 15 minutes with a maximum of five (5) units per instructional day. Medicaid Number Last Name First Name WVEIS Number Date of Birth Diagnosis Code School County Targeted Case Manager (Print) Month/Year Service Provided Procedure Code T1017 SE Types of Contact: 1. Face to Face 2. Correspondence 3. Telephone Contact Date of Service Progress Note: Activity: Purpose: Type of Contact TCM Activity Individualized Service Note: Time In: Time Out: Total Minutes Signature & Credentials: Date: Date of Service Progress Note: Activity: Purpose: Type of Contact TCM Activity Individualized Service Note: Time In: Time Out: Total Minutes Signature & Credentials: Date: Date of Service Progress Note: Activity:
* Must be identified on the Service Plan Service Plan Date:__________________ Progress Notes – School Based Targeted Case Management Unit is 15 minutes with a maximum of five (5) units per instructional day. Medicaid Number Last Name First Name WVEIS Number Date of Birth Diagnosis Code School County Targeted Case Manager (Print) Month/Year Service Provided Procedure Code T1017 SE Types of Contact: 1. Face to Face 2. Correspondence 3. Telephone Contact Date of Service Progress Note: Activity: Purpose: Individualized Service Note: Type of Contact TCM Activity Time In: Time Out: Total Minutes Signature & Credentials: Date: Date of Service Progress Note: Activity: Purpose: Individualized Service Note: Type of Contact TCM Activity Time In: Time Out: Total Minutes Signature & Credentials: Date: Date of Service Progress Note: Activity:
TCMform.ElectronicRevisionSpeechVersionAugust2017.docx