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Admission Requirements Checklist
The referring agency will make every reasonable effort to supply the items listed in the Admission Requirements Checklist if the client is accepted for placement. If more information than is provided in the Children's Service Referral Application is required to determine client eligibility for admission, the provider agency should request in writing the additional information from the referring agency.
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Medical Exam |
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Most Recent Treatment Plan |
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Current Medicaid / Insurance Card |
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Medical Necessity Form |
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254 Authorization Form |
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Most Recent Psychological / Psychiatric Evaluation(s) |
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Previous Placement Discharge Summary(ies) |
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Individual Education Plan (if applicable) |
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Copy of Birth Certificate |
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Copy of Social Security Card |
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Immunization Records |
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Completed Consent Forms (Program should forward to referring agency prior to admission) |
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Copies of Court Orders |
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Signed Homebound Form (if applicable) |
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Pre-Admission Assessment (if applicable) |
* This is a printer friendly version of the original page, made to save you ink and paper.
Admission Requirements Checklist
The referring agency will make every reasonable effort to supply the items listed in the Admission Requirements Checklist if the client is accepted for placement. If more information than is provided in the Children's Service Referral Application is required to determine client eligibility for admission, the provider agency should request in writing the additional information from the referring agency.
|
Medical Exam |
|
|
Most Recent Treatment Plan |
|
|
Current Medicaid / Insurance Card |
|
|
Medical Necessity Form |
|
|
254 Authorization Form |
|
|
Most Recent Psychological / Psychiatric Evaluation(s) |
|
|
Previous Placement Discharge Summary(ies) |
|
|
Individual Education Plan (if applicable) |
|
|
Copy of Birth Certificate |
|
|
Copy of Social Security Card |
|
|
Immunization Records |
|
|
Completed Consent Forms (Program should forward to referring agency prior to admission) |
|
|
Copies of Court Orders |
|
|
Signed Homebound Form (if applicable) |
|
|
Pre-Admission Assessment (if applicable) |
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Billie Hardee 
