Ccs Medical Therapy Plan - California
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1
2State of California—Health and Human Services Agency
Department of Health Care Services
Medical Therapy Program
CCS MEDICAL THERAPY PLAN
PT
OT
Change from previous Rx
NOTE: Physician’s signature and therapist’s signature are required in order for CCS MTP services to be provided and to
signify an approved therapy plan.
Child’s name
CCS number
Date
Date of birth
Treating diagnosis
Functional status (see page 2 for codes):
Mobility: __________________
Ambulation:_______________
Community skills: __________
Toileting: ________________
Dressing: _________________
Transfers: ________________
Home skills: ______________
Bathing: _________________
Feeding: _________________
Other: ___________________________________________________________________________
Treatment plan:
Gait training
Functional ADLs
MTU conference
Transfer training
Community skills
Monitor
Functional mobility
Modalities
Consultation
Therapeutic exercise
Splinting (UE/LE)
Evaluation
School program
Home program
Discharge from MTP
Functional goals and objectives to meet the goals:
Benefits of previous therapy
Rehab potential:
Good
Fair
Limited
Frequency
Duration
Proposed date of initiation
Therapist’s signature
Printed name
Medical therapy unit
County
Physicians: Please review the above and indicate any changes or additions to the information provided and sign below.
Precautions
Physician’s signature
Date
Proposed date of medical
(re)evaluation
Original—File in MTU Case Record
Photocopy 1—Send to Parent/Caregiver
Photocopy 2—Send to Local Educational Agency (LEA)
Special Education Local Plan Area (SELPA)
Page 1 of 2
DHCS 4505 (09/07)
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Parent category: Medical