OCFS-LDSS-7006 (07/2022) FRONT

NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

INDIVIDUAL HEALTH CARE PLAN

FOR A CHILD WITH SPECIAL HEALTH CARE NEEDS

You may use this form or an approved equivalent to document an individual health care plan developed for a child with special health care needs.

A child with a special health care need means a child who has a chronic physical, developmental, behavioral or emotional condition expected to last 12 months or more and who requires health and related services of a type or amount beyond that required by children generally.

Working in collaboration with the child’s parent and child’s health care provider, the program has developed the following health care plan to meet the individual needs of:

Child Name:

Child date of birth:

/ /
Name of the child’s health care provider:

Physician

Physician Assistant

Nurse Practitioner
Describe the special health care needs of this child and the plan of care as identified by the parent and the child’s health care provider. This should include information completed on the medical statement at the time of enrollment or information shared post enrollment.

Identify the caregiver(s) who will provide care to this child with special health care needs:

Caregiver’s Name	Credentials or Professional License Information (if applicable)

OCFS-LDSS-7006 (07/2022) REVERSE

NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

INDIVIDUAL HEALTH CARE PLAN

FOR A CHILD WITH SPECIAL HEALTH CARE NEEDS

Describe any additional training, procedures or competencies the caregiver identified will need to carry out the health care plan for the child with special health care needs as identified by the child’s parent and/or the child’s health care provider. This should include information completed on the medical statement at the time of enrollment or information shared post enrollment. In addition, describe how this additional training and competency will be achieved including who will provide this training.

This plan was developed in close collaboration with the child’s parent and the child’s health care provider. The caregivers identified to provide all treatments and administer medication to the child listed in the specialized individual health care plan are familiar with the child care regulations and have received any additional training needed and have demonstrated competency to administer such treatment and medication in accordance with the plan identified.

Program Name:

facility id number:

Program Telephone Number:

( )
Child care provider’s name (please print):

Date:

/ /
Child care provider’s signature:

X
I agree this Individual Health Care Plan meets the needs of my child.	Yes	No

I give consent to share information about my child's allergy with all program caregivers in a non-discreet way. I support the strategies the program implements to keep my child from being exposed to known allergen(s). I acknowledge these strategies may include visual reminders that may result in the disclosure of my child's confidential allergy information to non-child care staff.	Yes	No

Signature of Parent:

X	Date:

/ /

Individual Health Care Plan for a Child with Special Health Care Needs

OCFS-7006, Individual Health Care Plan for a Child with Special Health Care Needs

2022-07-29