Get Mn Dhs-7109 2020-2025

This guide provides users with a clear and structured approach to completing the MN DHS-7109 form, which is essential for developing an Individual Treatment Plan (ITP) for Early Intensive Developmental and Behavioral Intervention (EIDBI). The instructions will help ensure that all necessary information is submitted accurately and promptly.

Follow the steps to complete the MN DHS-7109 form accurately.

1. Click ‘Get Form’ button to access the document and open it for editing.
2. Begin by providing the date on which the ITP is being completed. Choose whether this is an initial ITP or an ITP progress monitoring by selecting the appropriate option.
3. Fill in A. Personal information for the person receiving services. Include fields such as first name, last name, date of birth, age, address, and provide a member ID if applicable.
4. Complete the parent/guardian information for both Parent 1 and Parent 2/guardian, ensuring correct relationships and contact details are entered including email addresses.
5. In section B, provide the agency provider name, taxonomy code, email, phone number, and NPI number for the treating provider. Ensure information is accurate to facilitate service authorization.
6. For section C, indicate the EIDBI service requested, number of hours per week, and the setting where the service will take place. Specify the treatment method, whether individual or group, and the frequency of progress monitoring.
7. In section D, enter the specific service details, including start date, end date, procedure codes, and pay to provider NPI number. Indicate the total number of service units required.
8. Section E requires you to detail the person’s greatest strengths and needs as well as family goals for the intervention. Be specific to create a relevant treatment plan.
9. If applicable, complete section F on the Functional Behavioral Assessment, providing necessary details about interventions and target behaviors.
10. In section G, outline the primary EIDBI treatment goals, including long-term objectives, along with relevant developmental domains and monitoring updates.
11. For section H, summarize current services the person is receiving and any coordination efforts surrounding those services.
12. Address the coordinated care conference in section I, summarizing outcomes and communication across the EIDBI team.
13. In section J, document progress made during the reporting period along with any significant changes affecting the person’s condition.
14. Lastly, complete section K focusing on the transition planning, ensuring involvement details and rationale for changes are included.
15. Once all sections are filled out, review for accuracy. Save your changes, then download or print the completed form for submission.

Complete your submission of the MN DHS-7109 form online today to ensure timely authorization of services.