Authorized dates Chosen provider type(s) and rate(s) Start and end, if Plan Service Element & Service # Unit not same as PSW, independent contractor, provider Per year Code Units Type plan year organization, general business, etc. (Frequency) [x] [] List identified needs that this service will address: Person’s preference on how this service is delivered: [] List identified needs that this service will address: Person’s preference on how this service is delivered: Chosen K Plan Residential Service This section may be removed if not applicable; indicate by using the provided dropdown. Complete the following only if the person chooses RESIDENTIAL services:
Service Element & Service Code # Units Unit Type Per (Frequency) Authorized dates Chosen provider type(s) and rate(s) PSW, independent contractor, provider organization, general business, etc. Plan year [x] Start and end, if not same as plan year [] List identified needs that this service will address: Person’s preference on how this service is delivered: [] List identified needs that this service will address: Person’s preference on how this service is delivered: Chosen K Plan Residential Service This section may be removed if not applicable; indicate by using the provided dropdown. Complete the following only if the person chooses RESIDENTIAL services:
4-Large_Print_ISP_6-18-2015.docx