2013 Individual Plan Of Care (Ipoc) / Individual Treatment Plan Template
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1
2Individual Plan of Care (IPOC) / Individual Treatment Plan
Agency:
Absolute Total Care/
BlueChoice Health
First Choice by
United Healthcare
Cenpatico
Plan Medicaid
Select Health
Community Plan
Phone: 866-694-3649
Phone: 866-902-1689
Phone: 866-341-8765
Phone: 866-761-7692
Fax: 866-534-5976
Fax: 877-664-1499
Fax: 888-796-5521
Fax: 877-821-7350
NA
Client Name (Last, First, MI):
ID #:
Medicaid #:
If “YES,” Existing Authorization #:
Authorization Adjustment:
YES
NO
2. Diagnosis and Code / Justification for Treatment (see
1. Presenting Problem:
initial IPOC if addendum):
3. Proposed Treatment Process:
Based on master problem list, identify specific goals/objectives to address the problem(s). Each goal should be
accompanied by measurable objectives leading to attainment of goal(s).
a. Date
b. Type of
c. Units
d. Days per
e. Goals/measurable objectives/criteria for
f. Target
Service
Service
per Day
Week
achievement
Expected
(select
from appropriate
Ordered
Persons responsible for service delivery
Achievement
drop-down menu)
Date
Discrete
Bundled
a)
b)
a)
b)
a)
b)
a)
b)
a)
b)
a)
b)
a)
b)
a)
b)
a)
b)
a)
b)
a)
b)
a)
b)
a)
b)
Clinician Signature, Title, and Date:
IPOC 1/13
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