Form 6517, Individual Program Plan (IPP) Service Review

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Effective Date: 9/2020


Updated: 9/2020


Case managers are required to monitor services periodically during the Individual Plan of Care (IPC) year. The schedule for monitoring services is included in Appendix VIII, Case Manager’s Review Schedule, of the Deaf Blind with Multiple Disabilities (DBMD) Program Manual. This optional form is available for DBMD program providers to use when conducting case manager reviews. See 40 Texas Administrative Code (TAC) Section 42.223 for specific requirements regarding case manager reviews.


When to Prepare

The case manager must meet face-to-face with the individual in accordance with the schedule in Appendix VIII of the DBMD Program Manual to:

  • review whether the DBMD Program services and Community First Choice (CFC) services are being provided as outlined in the IPC and IPP;
  • review the individual’s progress toward achieving the goals and objectives described in the IPP for each DBMD Program service and CFC service;
  • determine if the services are meeting the individual’s needs;
  • determine if the individual’s needs have changed;
  • review assessments, evaluations and progress notes prepared by service providers since the previous review;
  • determine if a service backup plan is needed for any services identified as critical to the individual’s health and safety; and
  • determine if a service backup plan, if implemented, was effective.

If the IPP service review is not completed within the scheduled period specified in the DBMD Program Manual, document the reason in the comments section.


The case manager must complete this review and send a copy to the individual/legally authorized representative (LAR) and the Financial Management Services Agency (FMSA), if applicable. The FMSA representative, if applicable, should review and communicate with the case manager and/or individual/legally authorized representative, as appropriate, to make service corrections, as needed.

Form Retention

Keep this form according to the record retention requirements documented in 40 TAC Section 49.307, Contracting For Community Services.

Detailed Instructions

Name of Individual — Enter the name of the DBMD/CFC participant.
Medicaid No. — Enter the individual's Medicaid number.
Review Date — Enter the date of the service review.
Next Review Date — Enter the date that the next service review is due.
DBMD Program Provider — Enter the name of the DBMD Program provider.
DBMD Vendor Number – Enter the contract number of the DBMD Program provider.
Financial Management Services Agency (FMSA) — Enter the name of the FMSA, if applicable.
FMSA Vendor Number — Enter the FMSA vendor number, if applicable.

Document the progress of each service authorized on the IPP/IPC on the IPP Service Review form. Additionally, the case manager must consider information in the progress notes provided by service providers of the following services:

  • Audiology Services
  • Behavioral Support Services
  • Day Habilitation
  • Dietary Services
  • Employment Assistance
  • Intervener
  • Intervener I
  • Intervener II
  • Intervener III
  • Occupational Therapy
  • Orientation and Mobility
  • Physical Therapy
  • Speech, Hearing and Language Therapy
  • Supported Employment  

For those authorized services requiring a service backup plan, respond to the following:

  • Did the Service Planning Team (SPT) determine any of these require a backup plan?
  • Did SPT create a backup plan for this service?
  • If the SPT did not create a backup plan for any of these services identified by the SPT as needing a backup plan, the case manager must convene the SPT to develop the backup plan immediately.
  • Was the service backup plan implemented?
  • Did the service backup plan meet the individual’s needs?
  • If the backup plan was implemented and did not meet the individual’s needs, the case manager must convene the SPT to revise the backup plan immediately.
  • In the "follow-up" section, document action taken on any issues identified when addressing the above items.
  • Any additional comments may be added in the general comments section found at the end of this form.

List any non-DBMD resources accessed — Document the non-DBMD resources accessed during the IPP service review.
General Comments — Use this area to document any general comments regarding DBMD services.
Location of the IPP Service Review — Enter the location.
Individual/LAR Signature and Date — The individual or LAR signs and dates the form.
DBMD Case Manager Signature and Date — The case manager signs and dates the form.
Other Signature and Date — Other signature and date is to be used when another individual attends the IPP service review, as desired by the individual/LAR.
FMSA Acknowledgment or Receipt and Date — The FMSA representative signs and dates the form, if applicable.