Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.
  1. 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

  2. Leave This Blank:

  3. This field is not part of the form submission.