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Virginia has adopted a statewide Individualized Family Service Plan (IFSP) form (.pdf). The form is also available in Spanish, Farsi, Korean and Vietnamese. This site includes instructions for completing the IFSP including page-by-page directions as well as considerations for Medicaid and Targeted reimbursement. A sample physician letter for referral and evaluation (.pdf) as well as a sample physician certification letter (pdf) can also be found on this site. An IFSP Flow Sheet shows the steps in the IFSP process including required procedural safeguards at each step in the process. The Local Regional Direct Services Committee of the Virginia Interagency Coordinating Council in collaboration with the Part C Office and other Part C providers has developed IFSPs which reflect implementation of Individualized Part C Early Intervention Supports and Services in Everyday Routines, Activities and Places. In accordance with the supports and services technical assistance document, the attached IFSPs are individualized for Polly and Samuel based upon the unique constellation of interests, needs, skills, challenges, resources, and priorities of each child and her/his family. For each IFSP, careful consideration was given to the following:· The outcomes match the family’s stated resources, priorities and concerns.· The outcomes are functional and focus on the child’s participation in activity settings that are important to the family.· Strategies to address the outcomes focus on and build upon learning opportunities and activities that occur throughout the child’s and family’s daily routine.· Identified Part C supports and services reflect the primary service provider model with appropriate support to the family and primary service provider from other disciplines.· The frequency and intensity of listed Part C supports and services change over time for Polly, Samuel and their families as each family’s need for support and guidance to implement IFSP strategies changes.These linked medical report and IFSPs have been reviewed by representatives of the Department of Medical Assistance Services and West Virginia Medical institute (WVMI) to ensure that the outcomes, short-term goals, etc. individualized for Polly (Medical information ; Initial IFSP ; Annual IFSP ) and Samuel are written in a way that meets third-party payor requirements.