EmailMe Form - HMCDDO Service Initiation/Transition Packet

INSTRUCTIONS: A service initiation planning meeting must occur before an individual begins services with a chosen service provider. If a person is changing providers, the current TCM is the lead coordinator for any transition which includes: transferring from one service provider to another, moving from an institutional placement to community services, transferring funding from another CDDO area, initiating new services with funding off the Service Access List, or other KDADS-approved access exception. The current TCM will coordinate the Transition Meeting, even when the transition is between TCM agencies. The Transition Meeting is to ensure any changes in service are planned for and implemented in a timely, well thought out manner and that all pertinent information is shared with the new service provider(s). For service transfers, both the current service provider and the new service provider must attend the meeting. Harvey-Marion County CDDO must also be notified and invited to attend this meeting. The Harvey-Marion County CDDO Director will determine need for HMCDDO attendance. The completed checklist will automatically go to the HMCDDO and then will be emailed to the participants of the planning team after meeting has concluded.

Provider(s)
MCO
CDDO
Other

Seasonal:
Medication:
Dietary:
Skin:

	TCM	Day Services	Residential Services	PCS	MCO
Current Provider (If Applicable)
New Provider (If Applicable)

	Complete	TCM	Provider	Yes	No	N/A	Other
Current PCSP & Addendums (completed within the last year)
Current Behavior Support Plan/Restrictive Interventions/Psychotropic Medications (including data)
Current Individual Justice Plan
Current Risk Assessments
Current IEP
Current BASIS
All behavior data collected since the last BASIS Assessment
Current Plan of Care
Receiving Extraordinary Funding
Current copy of Funding Request
3160 and/or current 3161
Current Needs Assessment & MR 10 Schedule
Current MR 1, MR 4, and/or MR 5
Psychological Evaluation
Initial CDDO paperwork (application, releases, Provider Choice Form, eligibility checklist / documentation)
Copy of Social Security Card
Copy of Payee or Conservatorship papers
Benefit information – SSI, SSDI, RR
HCBS Obligation / Spend down information
Copy of Medicaid Card, Medicare A, B, D and/or other insurance
Copy of Birth Certificate
Copy of Guardianship papers or Durable Power of Attorney
Copy of Kansas ID or other form of ID
Photo
Copy of Physician’s orders, nursing information & notes if there is a current medical condition being monitored
Special Needs (Dietary, OT, PT, seizures, etc…)
Any Legal papers (Probation, Protection from Abuse, Court orders, CINC Petitions, etc))
Transition Plan from DCF custody
Copy of pre-paid burial documents
Address change at the Post Office

The current provider must supply copies of all relevant documentation to the new provider.

1. Health/Medical / Medication / Adaptive Equipment / Special Needs Section:

2. Residential Supports Section:

3. Money Management Section:

4. Work/Day Supports:

5. Social/Behavioral Supports:

6. Community Involvement Section:

7. Family/Guardian/Friends/Natural Supports Section:

IF A MOVE IS INVOLVED:

Service Initiation / Transition Meeting Sign-In Section