Community Options Program
Intake Checklist
Congratulations
on acceptance of ________________ into the Community Options Program. The admission is scheduled for
_________________ at ____________.
Family is welcome to attend the admission, as you deem appropriate.
The
following is a list of information that is required from your office at the
time of admission. If this information
is not available, please contact me in advance so that arrangements can be
made.
_____Current
medical card and/or insurance card
_____Statement
on letterhead stating that DCBS is the responsible party for
payment of all bills
Medicaid/Insurance does not pay.
_____Up
to date Immunization record (including TB skin test completed within last 30
days)
_____List
of all current medications with a prescription to cover a 1-month (30 day)
period
_____Copy
of Birth Certificate
_____Current
Psychological/Psychiatric evaluation
_____Copy
of the Order of Commitment
_____
Results of a physical exam, which has been completed within the last 30 days. A pelvic exam within the last year.
_____Results
of a dental and visual exam within the last 6 months.
_____Results
of a VDRL completed within the past 30 days.
_____A
clothing letter as appropriate
_____DSS
114 form completed
_____Educational
passport. This should be obtained from
the school the child last attended.
Please include an IEP if one is available.
We
are looking forward to meeting with you on this date. Please call me at 606-677-6912 if there is a change of schedule
or you have further questions.
Colleen
Bivens, LCSW
Admissions
Coordinator