Care Coordination
515874017335500* Must be identified on the Service Plan Service Plan Date:__________________ Progress Notes – School Based Targeted Case ManagementUnit is 15 minutes with a maximum of five (5) units per instructional day.Medicaid NumberLast NameFirst Name908055080000 203203683000 298452730500 WVEIS NumberDate of BirthDiagnosis Code School14605336550021590-1587500 355604127500 -2349533655 CountyTargeted Case Manager (Print)Month/Year Service ProvidedProcedure Code1460541910-4254541910-3302041910 T1017 SETypes of Contact: 1. Face to Face 2. Correspondence 3. Telephone ContactDate of ServiceClick here to enter a date.Progress Note:Activity: Choose an item.Purpose: Choose an item.Individualized Service Note:Type of ContactChoose an item.TCM ActivityChoose an item.Time In:Time Out:Total MinutesSignature & Credentials:Date: Click here to enter a date. Date of ServiceClick here to enter a date.Progress Note:Activity: Choose an item.Purpose: Choose an item.Individualized Service Note:Type of ContactChoose an item.TCM ActivityChoose an item.Time In:Time Out:Total MinutesSignature & Credentials:Date: Click here to enter a date.Date of ServiceClick here to enter a date.Progress Note:Activity: Choose an item.Purpose: Choose an item.Individualized Service Note:Type of ContactChoose an item.TCM ActivityChoose an item.Time In:Time Out:Total MinutesSignature & Credentials:Date: Click here to enter a date. Date of ServiceClick here to enter a date.Progress Note:Activity: Choose an item.Purpose: Choose an item.Individualized Service Note:Type of ContactChoose an item.TCM ActivityChoose an item.Time In:Time Out:Total MinutesSignature & Credentials:Date: Click here to enter a date. Date of ServiceClick here to enter a date.Progress Note:Activity: Choose an item.Purpose: Choose an item.Individualized Service Note:Type of ContactChoose an item.TCM ActivityChoose an item.Time In:Time Out:Total MinutesSignature & Credentials:Date: Click here to enter a date. ................
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