[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-353744-105":53,"doc-detail-353744-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","individual-plan-of-care-dhcs-0020-rev-072019","Individual Plan of Care - DHCS 0020 - (REV 07/2019)","","Individual Plan of Care DHCS 0020 (REV 07/2019) is a structured form from the State of California Department of Health Care Services for documenting a participant’s care plan. It captures treatment authorization request and eligibility details, CBAS medical criteria, diagnoses with ICD codes, active medications and medication administration responsibilities, personal medical/mental health provider information, and functional status across ADLs/IADLs. It also records assistive devices, continence and nutritional data, living arrangement and household composition, and additional support and health services.",{"@graph":63,"@context":119},[64,80,102],{"@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/individual-plan-of-care-dhcs-0020-rev-072019/353744/",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/individual-plan-of-care-dhcs-0020-rev-072019/353744.png","ImageObject",442,249,{"name":88,"@type":89},"Đào","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-21","2026-09-22",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",8,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What information is collected in section (1) Treatment Authorization Request (TAR) and Eligibility?","Question",{"text":109,"@type":110},"It records the TAR type and includes reauthorization reasoning (if applicable), whether CBAS eligibility and medical necessity criteria are met, and which Medi-Cal 1115(a) Demonstration Waiver medical criteria categories apply.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How does the form document diagnoses?",{"text":114,"@type":110},"Section (2) lists diagnoses alongside corresponding ICD codes, with space for multiple diagnosis/ICD code pairs.",{"name":116,"@type":107,"acceptedAnswer":117},"What functional and care-support data are recorded beyond diagnoses and medications?",{"text":118,"@type":110},"Sections (5) through (9) capture ADL/IADL independence needs, current assistive/adaptive devices, continence and nutritional status, and living arrangement/household composition plus non-CBAS long-term support services if known.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},353744,1791687909,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":136,"language":137,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":138,"faqs":139,"seo_title":140,"seo_description":61,"update_tm":141,"read_time":142},1374402968488,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","STATE OF CALIFORNIA  \nDEPARTMENT OF HEALTH CARE SERVICES  \nINDIVIDUAL PLAN OF CARE  \nDHCS 0020 ( REV 07/2019)  \n| Center Name: |  |  |  | Provider \\# (NPI): |  |\n| --- | --- | --- | --- | --- | --- |\n| Participant Name: |  |  |  |  |  |\n| Date of Birth (MM/DD/YY) : |  |  | CIN: |  |  |\n| Gender: Male Female Transgender Male Transgender Female |  |  |  |  |  |\n| Managed Care Plan Name: |  |  |  |  |  |\n| Dates of Service: From:   To:   |  |  | Planned Days/Week (\\#  ) |  |  |\n| TAR Control Number (TCN): |  |  |  |  |  |\n| (1) TREATMENT AUTHORIZATION REQUEST (TAR) AND ELIGIBILITY |  |  |  |  |  |\n| Initial TAR Reauthorization TAR Change TAR TB Clearance Date (initial TAR only):  \u003Cbr>If this is a reauthorization TAR, the participant’s condition would likely deteriorate if the CBAS\u003Cbr>services were denied. Yes No N/A\u003Cbr>The individual meets all CBAS eligibility and medical necessity criteria and one or more of the following CBAS medical criteria categories as set forth in the current Medi-Cal 1115(a) Demonstration Waiver, entitled California Medi-Cal 2020:\u003Cbr>Category 1 : Nursing Facility Level A (NF-A) or above\u003Cbr>Category 2: Organic, acquired or traumatic brain injury and/or chronic mental disorder\u003Cbr>Category 3: Alzheimer’s disease or other dementias at moderate to severe level\u003Cbr>Category 4: Mild cognitive impairment including Alzheimer’s disease or other dementias\u003Cbr>Category 5: Individuals who have developmental disabilities |  |  |  |  |  |\n| (2) DIAGNOSES AND ICD CODES |  |  |  |  |  |\n| Diagnosis | ICD Code | Diagnosis |  |  | ICD Code |\n| 1. |  | 2. |  |  |  |\n| 3. |  | 4. |  |  |  |\n| 5. |  | 6. |  |  |  |\n| 7. |  | 8. |  |  |  |\n| 9. |  | 10. |  |  |  |\n| 11. |  | 12. |  |  |  |\n| 13. |  | 14. |  |  |  |\n\nSTATE OF CALIFORNIA  \nDEPARTMENT OF HEALTH CARE SERVICES  \nINDIVIDUAL PLAN OF CARE  \nDHCS 0020 ( REV 07/2019)  \n| Participant Name: |  |\n| --- | --- |\n| Dates of Service: From:   To:   | CIN: |\n\n\n| Diagnosis |  | ICD Code | Diagnosis |  | ICD Code |\n| --- | --- | --- | --- | --- | --- |\n| 15. |  |  | 16. |  |  |\n| 17. |  |  | 18. |  |  |\n| 19. |  |  | 20. |  |  |\n| (3) MEDICATIONS |  |  |  |  |  |\n| No medications or supplements |  |  |  |  |  |\n| ACTIVE PRESCRIPTIONS |  |  |  | OVER-THE-COUNTER MEDICATION AND/OR SUPPLEMENTS |  |\n| 1. | 2. |  |  |  |  |\n| 3. | 4. |  |  |  |  |\n| 5. | 6. |  |  |  |  |\n| 7. | 8. |  |  | 1. |  |\n| 9. | 10. |  |  | 2. |  |\n| 11. | 12. |  |  | 3. |  |\n| 13. | 14. |  |  | 4. |  |\n| 15. | 16. |  |  | 5. |  |\n| 17. | 18. |  |  | 6. |  |\n| 19. | 20. |  |  | 7. |  |\n| 21. | 22. |  |  | 8. |  |\n| 23. | 24. |  |  | 9. |  |\n| 25. | 26. |  |  | 10. |  |\n| Center administers participant’s prescribed medication(s) Yes No\u003Cbr>Participant self-administers prescribed medication(s) at center Yes No |  |  |  |  |  |\n| (4) ACTIVE PERSONAL MEDICAL/MENTAL HEALTH CARE PROVIDER(S) |  |  |  |  |  |\n| NAME PROVIDER SPECIALTY ADDRESS PHONE |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n\nSTATE OF CALIFORNIA  \nDEPARTMENT OF HEALTH CARE SERVICES  \nINDIVIDUAL PLAN OF CARE  \nDHCS 0020 ( REV 07/2019)  \n| Participant Name: |  |\n| --- | --- |\n| Dates of Service: From:   To:   | CIN: |\n\n\n| (5) ADL/IADLs |\n| --- |\n| Independent: able to perform for self with or without device\u003Cbr>Needs Supervision: no physical help required but needs to be monitored, even with device\u003Cbr>Needs Assistance: physical help or cueing required, even with device\u003Cbr>Dependent: unable to do for self, even with physical help, cueing or device\u003Cbr>ADLs INDEPENDENT NEEDS SUPERVISION NEEDS ASSISTANCE DEPENDENT Ambulation Bathing Dressing Self-Feeding Toileting Transferring |\n| IADLs INDEPENDENT NEEDS SUPERVISION NEEDS ASSISTANCE DEPENDENT Accessing Resources Hygiene Meal Preparation Medication Mgmt. Money Mgmt. Transportation |\n| (6) CURRENT ASSISTIVE/ADAPTIVE DEVICES |\n| None\u003Cbr>Wheelchair Walker Gait Belt Crutches Hoyer Lift Cane\u003Cbr>Dentures Glasses or Other Vision Aids Orthosis/Prothesis\u003Cbr>Hearing Devic","cbCaigiD9NHUO3e0","https://ap.wps.com/l/cbCaigiD9NHUO3e0","pdf",816954,26,"English","# (1) Treatment Authorization Request (TAR) and Eligibility\n# (2) Diagnoses and ICD Codes\n# (3) Medications\n# (4) Active Personal Medical/Mental Health Care Provider(s)\n# (5) ADL/IADLs\n# (6) Current Assistive/Adaptive Devices\n# (7) Continence Information\n# (8) Nutritional Information\n# (9) Living Arrangement/Household Composition and Non-CBAS Long Term Support Services\n# Support Services (in addition to CBAS)\n# (10) Other Health Services (if known)","[{\"question\":\"What information is collected in section (1) Treatment Authorization Request (TAR) and Eligibility?\",\"answer\":\"It records the TAR type and includes reauthorization reasoning (if applicable), whether CBAS eligibility and medical necessity criteria are met, and which Medi-Cal 1115(a) Demonstration Waiver medical criteria categories apply.\"},{\"question\":\"How does the form document diagnoses?\",\"answer\":\"Section (2) lists diagnoses alongside corresponding ICD codes, with space for multiple diagnosis/ICD code pairs.\"},{\"question\":\"What functional and care-support data are recorded beyond diagnoses and medications?\",\"answer\":\"Sections (5) through (9) capture ADL/IADL independence needs, current assistive/adaptive devices, continence and nutritional status, and living arrangement/household composition plus non-CBAS long-term support services if known.\"}]","Individual Plan of Care - DHCS 0020 - (REV 07/2019) | PDF",1790107032,9]