Individual Service Plan Individual Outcomes Page 2
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2F-20445A Page 2
INSTRUCTIONS – INDIVIDUAL SERVICE PLAN – INDIVIDUAL OUTCOMES
No.
Title
Description
1
Waiver Program
Indicate the waiver program serving the applicant/participant
2
Support and Service Coordinator/Care
Enter the Support and Service Coordinator/Care Manager and Agency Name
Manager, Agency
3
Participant Name
Enter the full legal name: last name, first name, middle initial and any suffix (e.g. Jr.)
4
Medicaid ID Number
Enter the ten digit Medicaid Number
5
Outcome Number
Assign a number corresponding to each individual outcome listed. The outcomes
should be listed in order of their priority (as designated by the applicant/participant)
6
Desired Outcome(s) Addressed in Service
Describe the individual outcome identified by the applicant/participant. Each SPC
Plan
code or paid/unpaid informal support listed on the 20445 should support the pursuit of
an individual outcome.
7
Outcome Status or Progress Update
Note any progress or update status of the individual outcome. Note ‘new’ if this is a
new outcome being added. Indicate person(s)/agency responsible or who have a role
in the attainment of the outcome.
8
Date
Enter the date the outcome was developed, updated or achieved, as applicable.
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