
Nt Identification Number (ND Number) County of Residence State ZIP Code Level of Care (LOC) Screening Effective Date SECTION II. SERVICES (formal) SERVICE PROVIDER PROVIDER NUMBER UNITS PER MONTH UNIT RATE Contingency Plan COST/MONTH Total Cost SECTION III. VINELAND SCORE Communication Daily Living Socialization Motor V-scale Score Total Score SECTION IV. SIGNATURES I am aware that I may have a recipient liability/ service fee. I selected the services listed above. I selected.
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How to fill out the ND SFN 600 online
The ND SFN 600 is an essential document used for participant service plans by the North Dakota Department of Human Services. This guide provides clear and supportive instructions to help users fill out the form online efficiently.
Follow the steps to complete the ND SFN 600 online.
- Press the ‘Get Form’ button to access the ND SFN 600 form and open it in your preferred editor.
- In Section I, provide your client identification details. Fill in the last name, first name, and middle name, followed by the physical address, city, client identification number, county of residence, state, and ZIP code.
- Proceed to Section II to outline the services. Here, you will need to list each service required, the corresponding provider, provider number, units per month, unit rate, contingency plan, and total cost.
- In Section III, input the Vineland score. Complete each category: communication, daily living, socialization, and motor, and ensure to indicate the total score.
- Section IV requires signatures. Confirm your understanding of the recipient liability and service fees by signing where indicated. You will also need to enter an effective date for the plan and have the service manager sign as well.
- In Section V, evaluate any restrictions by identifying behaviors that necessitate a restriction and documenting current and past restrictive plans. Each member involved should sign and date this section.
- Finally, Section VI focuses on the waiver risk assessment. Document assessment dates, strengths, needs, goals, and tasks for several categories. Be sure to include any relevant changes during six-month reviews.
- Once all sections are completed and verified, you can save your changes, download the form, print it out, or share it as needed.
Complete your ND SFN 600 form online today for a streamlined process.
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