Early Intervention- Plan Of Care (POC)/Progress Note

Childs Name: AKA: Medicaid #:

DOB: Sex: Related ICD 10 Diagnosis:

Current Evaluation Date: IFSP Date: Authorization Date: Start End

This plan is: Initial POC Ongoing POC/Progress Note (No More Than 170 days)

Agency’s Name: Individual Provider Name:

Service Type: EI Individual Session Early Intervention Medicaid Procedure Code: T1027SC

Domain(s): Gross Motor: Fine Motor: Communication: Cognitive: Social-Emotional: Adaptive-Self Help:

If Ongoing POC - Progress toward meeting IFSP Outcomes:

IFSP Outcomes [New: yes ✔ no ]

Goals:

Specific Activities That Will Occur In Order To Achieve The Stated Goal(s) or Outcome(s):

Frequency/Intensity/Duration/Location/Payor:
(Note: Authentic to increase or decrease frequency, intensity or duration for the recommended services on the IFSP must be made by
the IFSP TEAM in advance)
Frequency: Intensity: Duration: Location: Payor:
Medical Necessity: If child is a Medicaid recipient, the services reimbursed by Medicaid must be medically necessary (see IFSP Form
G).

I am in agreement with the proposed Plan of Care and authorize the plan discussed during: Consult ✔ Visit with child & family ✔
Licensed Professional’s Name: Professional Credentials:

Licensed Professional’s Signature: Date:

ITDS Signature: Date: Copy to family ✔ Copy to FSC ✔

Please Sign Legibly