Consumer Name: * Consumer Medicaid ID: * Agency Name: * Agency CSS Medicaid ID: * Rehabilitation Goal 4 from CRNA: Valued Life Role: Wellness Dimension: Strengths Related to Goal: KSR Development/Measurable Objective #1: Responsible Band Location Band # # of CSS Intervention(s) Frequency Duration Credential # of Service Units HCPCS Code KSR Development/Measurable Objective #2: Responsible Band Location Band # # of CSS Intervention(s) Frequency Duration Credential # of Service Units HCPCS Code KSR Development/Measurable Objective #3: Responsible Band Location Band # # of CSS Intervention(s) Frequency Duration Credential # of Service Units HCPCS Code Page 5 of 8 Community Support Services Individualized Rehabilitation Plan –
Consumer Name: * Consumer Medicaid ID: * Agency Name: * Agency CSS Medicaid ID: * Rehabilitation Goal 4 from CRNA: Valued Life Role: Wellness Dimension: Strengths Related to Goal: KSR Development/Measurable Objective #1: CSS Intervention(s) Responsible Credential Band # Location of Service Frequency Duration Band # # of Units HCPCS Code KSR Development/Measurable Objective #2: CSS Intervention(s) Responsible Credential Band # Location of Service Frequency Duration Band # # of Units HCPCS Code KSR Development/Measurable Objective #3: CSS Intervention(s) Responsible Credential Band # Location of Service Frequency Duration Band # # of Units HCPCS Code Page 5 of 8 Community Support Services – Individualized Rehabilitation Plan
CSS_Blank_IRP_Form.docx