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Texas Department of Aging Medically Dependent Children Program Form 2410
and Disability Services October 2008
Medical-Social Assessment and Individual Plan of Care
Individual Information
Name IPC Period (From – To)
/ / – / /
1. Date of Birth 2. Medicaid No. 3. Social Security No.
4. Primary Caregiver(s) 5. Caregiver’s Area Code and Telephone No.
6. Relationship to Applicant/Consumer 7. MN-AED 8. RUG 9. Date TMHP-MN
10. IPC Submission 11. Name of Applicant’s/Consumer’s Physician 12. Physician’s Area Code and Telephone No.
Initial Annual
13. Physician’s Address 14. City 15. State 16. ZIP
17. Initial Case Only — Indicate the applicant’s location at start of eligibility determination:
Hospital NF Home Other:
Part I — Medical Assessment (to be completed by MDCP nurse) Mark box if additional pages of health information are attached.
18. The following medical information was obtained from:
Family Physician Other:
19. Diagnosis:
19a(Primary)- 19d-
19b- 19e-
19c- 19f-
20. Ventilator: Yes No If Yes, briefly describe type and frequency of use:
21a. Give dates and reasons for any hospitalizations within the past 12 months:
21b. List recent acute illnesses requiring physician evaluation/treatment/interventions:
21c. List any planned/potential inpatient or outpatient hospitalizations within the next six months:
22a. Health Information:
22b. Describe current treatments:
22c. Describe medical equipment/assistive devices in use or needed:
22d. Prognosis, if known:
22e. Allergies:
23. Caregivers: Does the primary caregiver state that he/she is able to care for the applicant/consumer? .................... Yes No
24. Does the primary caregiver state that he/she is able to provide consumer-specific training to providers? ............... Yes No
25. Short-term Goals (consult with case manager):
26. Long-term Goals (consult with case manager):
Signature — MDCP Nurse Date Region Area Code and Telephone No.
Form 2410
Page 2/10-2008
Name IPC Period (From – To)
/ / – / /
Part II A — Social Assessment (to be completed by the case manager)
Describe the family’s home and community factors that contribute to the applicant’s/consumer’s care at home. Include any relevant
socioeconomic, psychological or health-related issues affecting the applicant’s/consumer’s care. Address health status of all primary
caregivers. Attach additional pages, if necessary.
27. Applicant’s/Consumer’s Functioning (physical, emotional, cognitive, behavioral):
28. Household Member(s)/Relationship to Applicant/Consumer and Ages:
29. Abilities/Limitations to Provide Care of:
29a. Primary Caregiver(s):
29b. Others in Household:
30. Family Relationship/Dynamics:
31a. Financial Resources/Limitations (include HIPP):
31b. Caregivers’ Work Schedules:
32. Community Resources:
33. School District Services:
a. Date of latest Admission, Review and Dismissal (ARD) meeting: / /
b. Homebound Education: Hours per Day Check here if home-schooled by choice.
c. Attends Public School: Hours per Day Type: Regular Special Ed. Other (specify):
d. School Transportation Provided by: Family School Dist. Other (specify):
34. Other Inclusion Activities:
35. Permanency Plans:
36. Special Needs/Considerations (not described above that impact applicant’s/consumer’s care):
37. Describe any safety or environmental health hazards: 38. Actions/recommendations:
a. None observed a. None required
b. Electrical/structural: b.
c. Other: c.
Signature —Case Manager Date Region Area Code and Telephone No.
Form 2410
Page 3/10-2008
Name IPC Period (From – To)
/ / – / /
39. – 40. Part II B — MDCP Schedule Planning Grid — Schedule must reflect plan for use of MDCP hours
Scheduling codes are listed in ( ) below. Note: Providers may deliver services overnight, but may not bill for hours during which the
nurse or attendant was asleep.
Week 1 Week 2
Time Sun Mon Tues Wed Thurs Fri Sat Time Sun Mon Tues Wed Thurs Fri Sat
12 mid 12 mid
1 am 1 am
2 am 2 am
3 am 3 am
4 am 4 am
5 am 5 am
6 am 6 am
7 am 7 am
8 am 8 am
9 am 9 am
10 am 10 am
11 am 11 am
12 noon 12 noon
1 pm 1 pm
2 pm 2 pm
3 pm 3 pm
4 pm 4 pm
5 pm 5 pm
6 pm 6 pm
7 pm 7 pm
8 pm 8 pm
9 pm 9 pm
10 pm 10 pm
11 pm 11 pm
41. Total Child Care Hours (parent at work, school or job training) Needed Per Week:
42. Private Insurance (I) (hours/week) 43. Non-Waiver Services
a. Nursing hrs a. School (S) hrs
b. PT, OT or Speech Therapy hrs b. Personal Care Services (PCS) hrs
44. Medicaid: (CCP) and/or Home Health (HH) (hours/week) 45. Services Provided by Family (hours/week)
a. CCP Private Duty Nursing hrs a. Hands-on Skilled/Personal Care (P) hrs
b. PT, OT or Speech Therapy hrs b. General Supervision (P) hrs
c. Home Health Services hrs c. Paid Child Care (CC) hrs
46. MDCP Services (hours/week) Specify provider type – nurse (N) or attendant (ATT)
a. Respite Care (R or FR) N or ATT hrs
b. Adjunct Supports (A or FA) N or ATT hrs
Signature — Case Manager Date Region Area Code and Telephone No.
Applicant’s/Consumer’s/Caregiver’s Name (Type or Print) Applicant’s/Consumer’s/Caregiver’s Signature Date
Form 2410
Page 4/10-2008
Name IPC Period (From – To)
/ / – / /
Part II C — Individual Plan of Care Summary
47. MDCP Services
Yes No Comments:
47a. Respite
47b. Adjunct Support Services
– Child Care
– Independent Living
– Post Secondary Ed
47c. Adaptive Aids
47d. Minor Home Modifications
47e. Financial Management Services
47f. Transition Assistance Services
48. Difficulty finding provider of choice: Yes No
49. If Yes, describe:
50. Services/Equipment Requested from Other Agencies: Each item must be addressed on Item 51 below (contact/follow-up
schedule).
50a. Service/Equipment Requested 50b. Agency Providing Service 50c. Date Requested 50d. Status
51. Case Manager Contact/Follow-up Schedule (must include a face-to-face visit at a minimum of every six months).
51a. Purpose of Contact 51b. Time Frame or Date of Contact 51c. Method of Contact
Plan Revisions/Changes At Consumer’s/Family’s Request By Telephone By Mail
All Initial Plans: (Confirm services
30 Days from Plan Start Date By Telephone
started as planned.)
Annual Reassessment Before Start of Next Plan Year Six-Month Face-to-Face Visit
Signature —Case Manager Date Region Area Code and Telephone No.
Form 2410
Page 5/10-2008
Name IPC Period (From – To)
/ / – / /
Part III — MDCP Applicant/Consumer Plan of Care/Budget Worksheet
52. IPC: Initial Annual
53. RUG: Maximum Annual Cost Limit: $
54. SSI Eligible: Yes No 54a. Date Verified:
55a. Non SSI Applicant/Consumers – Disability Determination Date / /
55b. Latest Medical Eligibility Date / /
56. Respite (R)/Adjunct Support Services (A): Child Care Independent Living Post Secondary Ed
a. R, A, FR e. Hours/ f. No. of g. Total No. of h. Rate per
b. From Date c. To Date d. Provider Type X = @ = i. Cost
or FA Week Weeks Hours Hour
X = @ =
X = @ =
X = @ =
X = @ =
X = @ =
X = @ =
X = @ =
X = @ =
56 j. Total 1:
57. Minor Home Modifications
a. Type of Modification b. Estimated Cost
c. Total Amount This Request = Subtotal
d. Previous Expenditures for Home Modifications
e. Add c (Subtotal) + d = – $7500 lifetime service limit.
If less than $7500, continue. If total is more than $7500, revise plan.
f. Add specification fee, if applicable. Fee is not included in the lifetime service limit.
Total 2:
g. Home Modification Maintenance/Repair: may not exceed $300/year –
not included in lifetime service limit = Total 3:
58. Adaptive Aids
b. Estimated Cost
a. Type of Adaptive Aid
(Total 4 may not exceed $4000 per IPC period)
c. Total 4:
59. Add Totals 1 + 2 + 3 + 4 = Grand Total (must not exceed annual cost limit)
If this total is below the maximum cost limit, note that the full maximum cost limit remains available should the consumer require any
plan changes during the plan year.
Signature —Case Manager Date Region Area Code and Telephone No.
Form 2410
Page 6/10-2008
Name IPC Period (From – To)
/ / – / /
60. Name of Primary Caregiver 61. Relationship to Applicant/Consumer
Part IV — Individual Plan of Care – Signature/Approval
62. Applicant’s/Consumer’s/Caregiver’s Approval:
DADS offers a number of services and provider types in MDCP from which families may choose. Your signature on this
plan is required in order to authorize services. However, your signature on this form in no way affects your right to request
a fair hearing if you disagree with this plan of care.
You have the right to make a change in the plan of care before the end of the plan year. You can choose to authorize the
case manager to make such changes on your verbal instruction or you may choose to have any changes you request
signed before they are made final. Your choice in no way affects your right to request a fair hearing. (If you make no
choice, all changes you request will require your signature.) You will receive copies of any plan changes made during the
IPC period.
I understand that this plan of care is an alternative to institutional services, and that my signature is required for services to
be authorized. I understand that my signature does not affect my right to a fair hearing if I disagree with this plan. I also
understand that I may make changes in the plan before the end of the IPC period by contacting my case manager, and
I want to be allowed to authorize changes to the Applicant/Consumer Plan of Care verbally to the case manager.
I understand that I will be provided with a copy of the revised plan.
I want DADS to require my signature to make changes to the Individual Plan of Care.
Applicant’s/Consumer’s/Caregiver’s Name (Type or Print) Applicant’s/Consumer’s/Caregiver’s Signature Date
63. Case Manager:
This plan was developed in collaboration with the applicant/consumer and/or primary caregiver(s). I have reviewed the rights
and responsibilities with the applicant/consumer/caregiver. I also have informed them that they have the right to make changes
in the Individual Plan of Care before the end of the period and may do so by contacting me.
Case Manager Name (Type or Print) Case Manager Signature Date
