Individual Service Plan Individual Outcomes

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Medicaid Services
F-20445A (03/2017)
INDIVIDUAL SERVICE PLAN – INDIVIDUAL OUTCOMES
1. Waiver Program:
2. Name - Support and Service Coordinator/Care Manager, Agency
CLTS Waiver (Indicate Target Group):
DD
MH
PD
CIP 1A
CIP 1B
BIW
CIP II
COP-W
COR
3. Name - Applicant/Participant
4. Medicaid ID Number
5. Outcome
Number
6. Desired Outcome(s) Addressed in Service Plan
7. Outcome Status or Progress Update
8. Date

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