INDIVIDUAL SERVICE PLAN for ADULTS INSTRUCTIONS

Appendix 3
INDIVIDUAL SERVICE PLAN
For Individuals with Developmental Disabilities Living in the Community
ADDENDUM C ISP REVISION FORM
Name:
(Last, First, Middle Initial)
Date of Current ISP:
Proposed Revision:
One Time Only
Permanent
WAIVER ID #:
96-__ __-6-__ __ __-__ __-__ __ __ __
(county) (social security number)
Effective Dates of Revision:
From:
To:
Nature of Revision: □ Face sheet □ Outcomes □ Action Plan □ Strategies □ Providers
□ Other:_____________________________________________________
Nature of Revision: Be Specific -- List all Provider changes (attach Transition Plan), changes in
Services (note Additions, Deletions or changes in Intensity / Frequency, changes in Outcomes or other
aspects of the current Individual Service Plan. Attach revised sections of the ISP. Please see Standards
for when IDT meeting must be held.
Justification for change in ISP:
Case Manager: Case Management Agency: Phone #: Date:
Revisions must be distributed to all IDT members, as well as the Regional Office.
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NM Developmental Disabilities Supports Division Individual Service Plan for Adults Instructions 5/30/2008