Healthcare Pre-ISP Form

HEALTHCARE PRE-ISP FORM

Patient Information

Date of Birth:    Gender:

Phone:    Email:

Emergency Contact

Relationship:    Phone:

Insurance / Payer Information

Policy / ID #:    Group #:

Medical History & Current Health

Current Supports, Services and Living Arrangements

Current Provider / Agency:

Private Residence    Group Home    Residential Facility    Other:

Functional Status, Strengths, and Goals

Behavioral, Safety, and Risk Information

Has there been a recent emergency department visit or hospitalization for behavioral or medical reasons?    Yes No

Consent to Assessment and Information Sharing

I authorize the collection of information necessary to develop an Individual Support Plan (ISP). I understand that information gathered will include medical history, behavioral observations, service history, and other relevant records. I authorize staff and contracted providers to communicate and exchange information for the purpose of assessment and ISP development in accordance with applicable privacy laws.

I understand that I may withdraw this authorization at any time by providing written notice, except to the extent that action has already been taken in reliance on this authorization. I acknowledge that refusal to provide information may limit the ability to provide services but does not affect my right to receive emergency care or to request alternate supports.

Privacy, Confidentiality, and Mandatory Reporting

All information collected during assessment and ISP development is confidential and will be handled in accordance with applicable privacy and health information laws. Certain information may be disclosed without consent where disclosure is required or permitted by law, including but not limited to mandatory reporting of abuse, imminent risk of harm, or as required by court order.

By signing below, I acknowledge that I have been informed of privacy protections and the circumstances under which my information may be shared.

Authorization Period

This authorization is effective as of the date signed and will expire on:    If no date is entered, this authorization will remain in effect until revoked in writing.

Acknowledgment and Certification

I certify that the information I have provided on this form is accurate to the best of my knowledge. I understand that intentional misrepresentation may affect eligibility for services and that material omissions may be grounds to deny or modify recommended supports.

I understand that participation in assessment and ISP development is voluntary and that I have the right to ask questions, request clarifications, and to receive a copy of the ISP once finalized.

HIPAA and privacy rules apply to my health information. By signing below I acknowledge receipt of the privacy notice on personal health information and authorize the use and disclosure described in this form.

Additional Information

Consent & Certification

Please indicate your acknowledgement and consent:

I consent to assessment and ISP planning as described above.

I consent to information sharing with providers and support persons involved in care, subject to any restrictions noted above.

Sign Now