Download Things to Consider When Writing Your Child`s Service Plan

Things to Consider When Writing Your Child’s Service Plan
1. Insurance Coverage - Please supply the following:
• Name of insurance company
• Deductible (specify if it’s per person or for the whole family)
• Co-pays amounts per month – For each: office visits, medical supplies, Emergency Room,
Hospitalizations, Durable Medical Equipment, Prescriptions
2. Doctor visits (Include Dental and Vision, if applicable)
• Every doctor’s name (primary and/or specialist; specify the specialty)
• Why the child will be seen, when the child is seen (eg monthly, every six months, etc; you don’t
have to give exact dates), how often the child is seen, and the co-pay amount or estimated cost
for each visit
3. Anticipated Hospitalizations and/or Surgeries
• When, where, for what reason, and the co-pay amount or estimated cost per visit
4. Professional Therapies (eg OT / PT / Speech)
• How often (1x per week for 45 minutes, etc.), goals (or what the therapist is working on with the
child), and the co-pay amount or estimated cost for each visit
5. Durable Medical Equipment (any non-disposable equipment (e.g. walkers, seats, etc))
• What the equipment is, why it is needed, and the co-pay amount or estimated cost (if known; if
not, it can be researched)
6. Medical Supplies (such as dressings, diapers/pull ups, formula, etc.; can be delivered)
• How many of each, how often they are being used, why they are being used, and the co-pay
amount or estimated cost per visit.
• (For example: 8 pull-ups per day, for incontinence, cost unknown; or Pediasure, 2 ½ cans daily
to boost nutritional intake to gain weight, $__ per can)
7. Pharmacy
• How many medications (listing is included in another form), how often the prescription is
refilled, and the copay amount or estimated cost for each refill (monthly, annually, etc)
8. Home Health or Nursing
• How often the service occurs, how long per visit, the Agency providing the services, and the copay amount or estimated cost for each visit
9. Contingency Plan
• We will need information on any plans that exist to address the following questions:
1. What plans are in place to get the child to a scheduled treatment?
2. What plans are in place if the caregiver(s) is/are temporarily or permanently unable to
provide care (including transportation) for the client?
3. Are there any long-term financial arrangements (this can include Wills or Trusts)?
10. Goals for Your Child
• Think of 3-5 goals for your child for the next 12 months. The goals need to be somewhat
measurable; I can help you with these, if you’d like.
ThingstoConsider
02.24.11