Form H1700-3, Individual Service Plan – Signature Page

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Effective Date: 8/2021


Updated: 6/2023


Form H1700-3 is used to:

  • record the applicant’s or member's choice to receive the STAR+PLUS Home and Community Based Services (HCBS) program as an alternative to nursing facility care;
  • document the applicant’s, member’s or authorized representative’s acceptance of the individual service plan (ISP); and
  • document the service coordinator’s verification that the applicant’s or member’s medical need and rationale for waiver services has been established by the managed care organization (MCO) and all services identified are appropriate to meet the needs of the applicant or member.


When to Prepare

Form H1700-3 is prepared by the service coordinator at the initial assessment, reassessment or ISP change.

Copies and Transmittal

The original or electronic Form H1700-3 is uploaded to the MCO's ISP folder in MCOHub and the MCO keeps a copy in the member’s case record. Copies are forwarded to the applicant, member and the authorized representative, if applicable.

Form Retention

The MCO must keep Form H1700-3 according to the retention requirements found in all Medicaid managed care contracts and federal regulations. The MCO must keep all original or electronic copies of this form in the applicant’s or member's case record for five years after services are terminated.

Detailed Instructions

Individual Service Plan Dates — MCO staff enter the begin and end dates of the ISP using mm/dd/yyyy format. For initial assessments, the MCO must use the ISP dates listed on Form H2065-D, Notification of Managed Care Program Services, received from Program Support Unit (PSU) staff.

Revision Date — Enter the date the ISP was revised if any changes were made during the ISP period. This line is left blank during the initial assessment and annual reassessment.

Applicant/Member Name — Enter the name of the applicant or member.

Medicaid ID No. or Applicant Social Security No. — Enter the applicant's or member's Medicaid number or Social Security number, if a Medicaid number is not available.

Freedom of Choice and Acknowledgment and Acceptance of the Individual Service Plan: The applicant, member or authorized representative prints their name, signs and dates the ISP signature page to acknowledge the freedom to choose between a nursing facility or HCBS and acknowledge their acceptance of the proposed or revised ISP. If the applicant or member is unable to write their name, the applicant or member enters an "X" as an identifying mark that must be witnessed. The witness must print and sign their name and enter the date they signed the form.

Note: If there is a revision during the ISP period, the service coordinator may obtain a verbal acknowledgment and acceptance of the revised ISP. Verbal acknowledgment and acceptance must be obtained within seven business days of the effective date of the change. The date and name of the person who gave the verbal acknowledgment and acceptance of the revised ISP must be documented on the applicant/member or authorized representative signature line.

Service Coordinator Verification: The service coordinator prints their name, signs and dates the ISP signature page to verify all waiver services identified are appropriate to meet the needs of the applicant or member and the proposed or revised ISP was developed, reviewed and approved by the service coordinator to establish eligibility for the STAR+PLUS HCBS program.