Individual Summary Sheets
(1)The name of the individual and his or her current address, previous address if the individual has lived in the home less than one year, date of entry into the home, date of birth, gender, marital status (for individuals 18 or older), religious preference, preferred hospital, medical prime number and private insurance number (if applicable), and guardianship status; and
(2)The name, address, and telephone number of the following (if applicable):
(a)The legal or designated representative, family, and people significant to the individual, and for a child, the parent and educational surrogate;
(b)The primary care provider and clinic preferred by the individual;
(c)The dentist preferred by the individual;
(d)The identified pharmacy preferred by the individual;
(e)The school, day program, or employer of the individual;
(f)The case manager of the individual, and for Department direct contracts, the Department representative; and
(g)Other agencies and representatives providing services and supports to the individual.
(3)For a child under the age 18, any court-ordered or contacts or limitations authorized by the child’s legal representative must also be included on the individual summary sheet.
Rule 411-325-0180 — Individual Summary Sheets,