HMCDDO Service Initiation/Transition Packet
INSTRUCTIONS: A service initiation planning meeting must occur before an individual begins services with a chosen service provider. If a person is changing providers, the current TCM is the lead coordinator for any transition which includes: transferring from one service provider to another, moving from an institutional placement to community services, transferring funding from another CDDO area, initiating new services with funding off the Service Access List, or other KDADS-approved access exception. The current TCM will coordinate the Transition Meeting, even when the transition is between TCM agencies. The Transition Meeting is to ensure any changes in service are planned for and implemented in a timely, well thought out manner and that all pertinent information is shared with the new service provider(s). For service transfers, both the current service provider and the new service provider must attend the meeting. Harvey-Marion County CDDO must also be notified and invited to attend this meeting. The Harvey-Marion County CDDO Director will determine need for HMCDDO attendance. The completed checklist will automatically go to the HMCDDO and then will be emailed to the participants of the planning team after meeting has concluded.
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  • TCM Day Services Residential Services PCS MCO
    Current Provider (If Applicable)
    New Provider (If Applicable)
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  • Provider(s)
  • The current provider must supply copies of all relevant documentation to the new provider.

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  • Complete TCM Provider Yes No N/A Other
    Current PCSP & Addendums (completed within the last year)
    Current Behavior Support Plan/Restrictive Interventions/Psychotropic Medications (including data)
    Current Individual Justice Plan
    Current Risk Assessments
    Current IEP
    Current BASIS
    All behavior data collected since the last BASIS Assessment
    Current Plan of Care
    Receiving Extraordinary Funding
    Current copy of Funding Request
    3160 and/or current 3161
    Current Needs Assessment & MR 10 Schedule
    Current MR 1, MR 4, and/or MR 5
    Psychological Evaluation
    Initial CDDO paperwork (application, releases, Provider Choice Form, eligibility checklist / documentation)
    Copy of Social Security Card
    Copy of Payee or Conservatorship papers
    Benefit information – SSI, SSDI, RR
    HCBS Obligation / Spend down information
    Copy of Medicaid Card, Medicare A, B, D and/or other insurance
    Copy of Birth Certificate
    Copy of Guardianship papers or Durable Power of Attorney
    Copy of Kansas ID or other form of ID
    Copy of Physician’s orders, nursing information & notes if there is a current medical condition being monitored
    Special Needs (Dietary, OT, PT, seizures, etc…)
    Any Legal papers (Probation, Protection from Abuse, Court orders, CINC Petitions, etc))
    Transition Plan from DCF custody
    Copy of pre-paid burial documents
    Address change at the Post Office
  • 1. Health/Medical / Medication / Adaptive Equipment / Special Needs Section:

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  • Seasonal:
    Just put N/A if there are no allergies in any one of these sections.
  • 2. Residential Supports Section:

  • 3. Money Management Section:

  • 4. Work/Day Supports:

  • 5. Social/Behavioral Supports:

  • 6. Community Involvement Section:

  • 7. Family/Guardian/Friends/Natural Supports Section:


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    *Billing for new Residential Provider starts the day the person served wakes up in the new Provider’s services / new home*
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  • Service Initiation / Transition Meeting Sign-In Section

    Please list all individuals involved in the meeting.