2. Date*
   Date
3. Rule 5 Provider:*
   -- Select One --Pat CorteseNorth Homes Inc.
5. Rule 5 Placement Check List (Needs to be done before placement)

   - Copy of Insurance card, front and back given to Itasca County at the time of placement, by Case Manager

   - 3rd party billing information and an authorization or denial sheet,  if on private insurance, to be provided to social worker.  (To speed the process up families can get this ahead of time)

   - Release of information to Private Insurance Company of applicable for Itasca County to send an receive information for prior authorization, provided by the Case Manager

   - Meeting with Case Manger, Family, and Itasca County Representative prior to placement to go over voluntary placement agreement,  Case Manager will set up the meeting.

   - Signature portion of Social Security Redirection Policy if on Social Social Security, by Case Manager

   - Copy of most recent IFCSP, from Case Manager

   - M.A. packet filled out, dated for the day of entry into placement.  IF, this isn't done and Itasca County receives a bill your agency will be billed.  By Case Manager 

   - IV-E Packet filled out,  by Case Manager

   - Case Plan, By Case Manager

   
   

7. Childs Name:*
8. Date of Birth:
   Date of Birth:
9. Parent/ Guardian Name:*
11. Childs Current Address:*
13. Legal Custodians Address if Different from Childs Current Address:
15. City*
16. State
17. Zip Code
19. Phone Number*
20. Any Tribal Affiliation? *
    -- Select One --YesNo
21. If Yes, who is the Affiliated Tribe?
23. Referral Source Name:*
24. Email Address*
26. Address
28. City
29. State
30. Zip Code
32. Phone Number*
33. Fax Number
35. School District, Current School, and Grade:*
36. Is a Itasca County Social Worker Assigned?*
    -- Select One --YesNo
37. If Yes, who is the social worker?
39. Proposed Placement:
40. Proposed Placement Date if known:
41. Childs Primary Care Doctor:*
43. Date SPR Team approved Rule 5 Assessment:*
    Date SPR Team approved Rule 5 Assessment:
44. Date of Last Diagnostic Assessment:*
    Date of Last Diagnostic Assessment:
45. Who was the Provider of the most recent DA?*
46. Mental Health Clinic, Providers, and Hospitals Contact Information:*
48. Childs Current Behaviors and when did they start? (Please be Specific)*
50. List of Services currently and historically. (Please be detailed) Parent/ Guardian's level of follow through: (be specific of services and agency providing)*
52. Have all community based options been used consistently, if not why?*
54. Upload Itasca County Release:*
55. Upload Rule 5 Assessor Release:*
56. Social Security Redirection Signature Form if on Social Social Security, Supplement Security income, or Retirement Survivors and Disability Income.
57. Upload Any Additional Information:
Leave This Blank:


59. 1. Receive an email copy of this form.
60. Email address

    This field is not part of the form submission.

61. Submit Submit and Print

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