Service Summary Form - Ocfs - New York State Page 2

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OCFS-8018 (1/2012)
Description of service provided:
Description of child’s response to service. Include progress towards any identified goals or intervention
strategies:
My signature verifies that the above service was provided.
HCI OR WSP NAME:
HCI OR WSP SIGNATURE:
DATE:
X
HCI SUPERVISOR OR WSP SUPERVISOR NAME:
HCI SUPERVISOR OR WSP SUPERVISOR SIGNATURE:
DATE:
X
HEALTH CARE INTEGRATION AGENCY(HCIA) / WSP AGENCY NAME:
PHONE #:
ADDRESS:
CITY:
STATE:
ZIP CODE:
NOTE: FOR HEALTH CARE INTEGRATION ONLY. SEE ACCOMPANYING PROGRESS NOTES DATED FOR THE
FOLLOWING CONTACTS:
CONTACT WITH WAIVER SERVICE PROVIDERS IN THE INDIVIDUALIZED HEALTH PLAN (IHP)
Date
Date
CONTACT WITH CASE PLANNER/CASE MANAGER IF CHILD IS IN FOSTER CARE
Date
Date

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