the Action Plan of this ISP. The providers approved below for these authorized services are responsible for carrying out this ISP and meeting the health and personal safety needs of this person. A b c d e f g (didd Use Only) Service Name Service Code Provider Name Site Name Start Date Unit Rate Units of Svc Deny & & & & & & & & Approve Deny Partially Type of Request Fund Source Provider Code Site Code End Date Unit Type Cost of Svc Approve 1 [ ] [ ] [ ] 2 [ ] [ ] [ ] 3 [ ] [ ] [ ] 4 [ ] [ ] [ ] 5 [ ] [ ] [ ] 6 [ ] [ ] [ ] 7 [ ] [ ] [ ] 8 [ ] [ ] [ ] 9 [ ] [ ] [ ] — If checked, the listing of requested / authorized services continues on the next page of this section. DIDD Review and Authorization of Services: Projected Total for ISP Year: $ Note: The total units for any combination of day services listed here in Section C.2 will be shown just for the type of Day Service with the highest unit rate. Day Services are (Title) (Date) (Authorizing Signature) limited to 243 days across any and all combinations of day services and settings. 2. Medicaid HCBS Waiver Services (Continued):
the Action Plan of this ISP. The providers approved below for these authorized services are responsible for carrying out this ISP and meeting the health and personal safety needs of this person. A b c d e f g (didd Use Only) Service Name & Type of Request Service Code & Fund Source Provider Name & Provider Code Site Name & Site Code Start Date & End Date Unit Rate & Unit Type Units of Svc & Cost of Svc Approve Deny Deny & Partially Approve 1 [ ] [ ] [ ] 2 [ ] [ ] [ ] 3 [ ] [ ] [ ] 4 [ ] [ ] [ ] 5 [ ] [ ] [ ] 6 [ ] [ ] [ ] 7 [ ] [ ] [ ] 8 [ ] [ ] [ ] 9 [ ] [ ] [ ] — If checked, the listing of requested / authorized services continues on the next page of this section. DIDD Review and Authorization of Services: Projected Total for ISP Year: $ Note: The total units for any combination of day services listed here in Section C.2 will be shown just for the type of Day Service with the highest unit rate. Day Services are limited to 243 days across any and all combinations of day services and settings. (Authorizing Signature) (Title) (Date) 2. Medicaid HCBS Waiver Services (Continued):
80.3.4.a%20-%20ISP%20Support%20Plan%20with%20Person%20Centered%20Prompts.docx