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Includes sections for description of services received, scope, unit and frequency, duration, provider, assessment identifying need, authorizing entity, and desired outcomes/goals. Collects informal supports, residential setting compliance responses, additional comments when questions are answered “No”, assessment information with reassessment timing, and fields for diagnosis, strengths, preferences, unmet service needs, goals, and risk management with triggers, responses, measures, and safeguards.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/authorization-summary-care-plan-form/353742/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/authorization-summary-care-plan-form/353742.png","ImageObject",442,249,{"name":88,"@type":89},"Terk","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-23","2026-09-22",true,{"@type":98,"interactionType":99,"userInteractionCount":47},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information is collected in the Summary Page section?","Question",{"text":108,"@type":109},"It collects enrollee name, date of birth, address, phone number, email address, and preferred language, along with authorization period and date issued.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How does the form document services the enrollee is currently receiving?",{"text":113,"@type":109},"It provides tables to list each service name, scope/description, unit and frequency, provider, duration/authorization period, contact information, assessment identifying need, authorizing entity, and desired outcome/goals.",{"name":115,"@type":106,"acceptedAnswer":116},"How is risk management captured in this form?",{"text":117,"@type":109},"It records each risk, associated trigger(s), known response(s), measures in place, and safeguard(s) to minimize risks to health and wellbeing.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},353742,1791350030,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":47,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":135,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":76},1099525198933,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","Summary Page  \nAuthorization Period  Date Issued   \n\n| Enrollee Name |  | Date of Birth |  |\n| --- | --- | --- | --- |\n| Address |  |  |  |\n| Phone Number |  | Preferred Language |  |\n| Email Address |  |  |  |\n\nIf you have a question or a problem regarding your services, call your care manager below,   [Care Manager Name]  at (xxx) xxx-xxxx  \nDescription of Services  \nUse this area to identify current services received by the enrollee. [ Duplicate boxes below as needed] .  \n\n| Name of Service |  |  |  |\n| --- | --- | --- | --- |\n| Scope/Description of Service |  |  |  |\n| Unit and Frequency of Service |  | Provider |  |\n| Duration/Authorization Period |  | Contact Information |  |\n| Assessment Identifying Need |  | Authorizing Entity |  |\n| Desired Outcome/Goals |  |  |  |\n\n\n| Name of Service |  |  |  |\n| --- | --- | --- | --- |\n| Scope/Description of Service |  |  |  |\n| Unit and Frequency of Service |  | Provider |  |\n| Duration/Authorization Period |  | Contact Information |  |\n| Assessment Identifying Need |  | Authorizing Entity |  |\n| Desired Outcome/Goals |  |  |  |\n\n\n| Name of Service |  |  |  |\n| --- | --- | --- | --- |\n| Scope/Description of Service |  |  |  |\n| Unit and Frequency of Service |  | Provider |  |\n| Duration/Authorization Period |  | Contact Information |  |\n| Assessment Identifying Need |  | Authorizing Entity |  |\n| Desired Outcome/Goals |  |  |  |\n\nInformal Supports  \nIdentify unpaid supports and their relationship to the enrollee. [ Duplicate boxes below as needed.]  \n\n| Name |  |  |  |\n| --- | --- | --- | --- |\n| Relationship/Title |  | Contact Information |  |\n| Service(s) Provided/ Support Role |  |  |  |\n| Unit and Frequency of Service |  |  |  |\n\nEnrollee Information  \n\n|  |  |  |  |\n| --- | --- | --- | --- |\n| Primary Care Manager |  | Secondary Care Manager |  |\n| Organization |  | Organization |  |\n| Primary Care Provider (PCP) |  |  |  |\n| PCP Contact Information |  |  |  |\n|  |  |  |  |\n| Medicaid/CIN \\# |  |  |  |\n| Primary Insurance Agency |  | Secondary Insurance Agency |  |\n| Enrollee ID |  | Enrollee ID |  |\n\nResidential Setting and Supports  \nUse this section to confirm that the individuals residential setting meets the HCBS settings rule.  \n\n| Is the residential address provided a community-based setting? | Yes ☐ No ☐ |\n| --- | --- |\n| Enrollee chose where they live now. | Yes ☐ No ☐ |\n| Enrollee can participate in the activities they like inside and outside of their home. | Yes ☐ No ☐ |\n| Enrollee can go to work if/ when they want to. | Yes ☐ No ☐ |\n| Enrollee can go to school if/ when they want or need to. | Yes ☐ No ☐ |\n| Enrollee can visit friends and family if/ when they want to. | Yes ☐ No ☐ |\n| Enrollee can enjoy food and snacks that they like whenever they want to. | Yes ☐ No ☐ |\n| Enrollee can easily move around their home and other places where services are received. | Yes ☐ No ☐ |\n| Use the space provided below for additional comments if the answer to any of the questions above is “No”. |  |\n|  |  |\n\nAssessment Information  \nInclude all applicable assessments. [ Duplicate boxes below as needed] .  \n\n|  |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| \u003Cbr>[Insert Assessment Name] | Date of Initial Assessment | XX/XX/XXXX | Most Recent Assessment Date | XX/XX/XXXX |\n|  | Anticipated Reassessment Date | (Month/Year) |  |  |\n\n\n|  |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| \u003Cbr>[Insert Assessment Name] | Date of Initial Assessment | XX/XX/XXXX | Most Recent Assessment Date | XX/XX/XXXX |\n|  | Anticipated Reassessment Date | (Month/Year) |  |  |\n\n\n|  |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| \u003Cbr>[Insert Assessment Name] | Date of Initial Assessment | XX/XX/XXXX | Most Recent Assessment Date | XX/XX/XXXX |\n|  | Anticipated Reassessment Date | (Month/Year) |  |  |\n\n\n|  |  |\n| --- | --- |\n| Diagnosis |  |\n|  |  |\n|  |  |\n\nStrengths, Preferences, Unmet Service Needs and Goals  \nUse this section to describe the strengths, preferences, unmet service needs and goals/desired o","cbCaicpxnenQo8gV","https://ap.wps.com/l/cbCaicpxnenQo8gV","pdf",424864,9,"English","# Summary Page\n# Services and Informal Supports\n## Description of Services\n## Informal Supports\n# Enrollee Information\n# Residential Setting and Supports\n# Assessment Information\n# Strengths, Preferences, Unmet Service Needs and Goals\n# Risk Management and Safeguards","[{\"question\":\"What information is collected in the Summary Page section?\",\"answer\":\"It collects enrollee name, date of birth, address, phone number, email address, and preferred language, along with authorization period and date issued.\"},{\"question\":\"How does the form document services the enrollee is currently receiving?\",\"answer\":\"It provides tables to list each service name, scope/description, unit and frequency, provider, duration/authorization period, contact information, assessment identifying need, authorizing entity, and desired outcome/goals.\"},{\"question\":\"How is risk management captured in this form?\",\"answer\":\"It records each risk, associated trigger(s), known response(s), measures in place, and safeguard(s) to minimize risks to health and wellbeing.\"}]","Authorization Summary - Care Plan Form | PDF",1790107031]