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Individualized Plan of Care (IPC) Documents

IPC Forms

Habilitation Support (effective August 2012)

ICAP Authorization (effective September 2012)

Revised Team Signature and Verification form (Revised March 2015)

Verification form - used in EMWS last step for submitting IPC

Helpful IPC Tools

"About Me" worksheet (Revised September 2012)

File Naming Convention - used in EMWS for uploading files

Functional Assessment - Sample
(Template is sample that can be used to explore the reasons behaviors are occurring and can be used to develop Positive Behavior Support Plan.)

Medication Assistance Record

"My Medical Services" worksheet

Participant Specific Training form

Plan of Care Worksheet for EMWS
        - example completed Child IPC
        - example completed Adult IPC

Planning Workbook for IPC

Positive Behavior Support Plan - Sample
(Template is sample to guide in building a Positive Behavior Support Plan. Other versions are acceptable provided the components of the IPC align with Chapter 45 of Wyoming Medicaid Rules.)

Request Goods & Services through Self-Direction: Step by Step Instructions

Rights, Responsibilities, and Restrictions Guide
(Case Managers can use this tool to review the Participant and guardian's rights and responsibilities at least every six months or more as needed.)

Rights, Responsibilities, and Restrictions Worksheet

Services and Rates

Supervision Level and/or Intervention Request
(Use this form if requesting a higher or lower support tier in Residential or Day Habilitation or requesting intervention units)

Waiver Application & Eligibility Guide - for Adult and Child DD Waivers

Supplemental Service Forms

For services included on a Participant's IPC, a supplemental form is completed by the provider and sent to the Case Manager before the IPC is submitted to the Division. Objectives are required for habilitation services but do not need to be sent to the Division with the IPC.

Checklist for requesting Specialized Equipment

Environmental Modifications

Goods & Services (Available if Self-Directing through PPL)

Skilled Nursing -physician's order form Posted 7-23-13

Specialized Equipment

Unpaid Caregiver Training (Available if Self-Directing through PPL)

Sample Objectives and Schedules

These are only samples and are not required to be used. Providers may develop their own schedules with input from the participant and team, which align with the documentation requirements listed in Chapter 45.

Example of Completed Objective & Schedule

Employment Objectives

Habilitation Objectives (For Supported Living, Res & Day Hab, Special Family Hab Home, Child Hab Services)

Personal Care Schedule - or PDF

Residential Habilitation Training Schedule

Respite Schedule - or PDF

Special Family Hab Home Schedule - or PDF

Sample Day Habilitation Schedule (With behavior plan and objective data collection components)

Sample Intervention Hours Schedule

Sample Residential Habilitation Schedule

Sample Task Analysis Sheet