Undivided's California Public Benefits and Insurance Template Library

• Sample Doctor Request for Assessment of Need: When you are applying for IHSS protective supervision, your child's doctor must fill out form SOC 821 that indicates your child has impairment in orientation, judgement, and memory. It may be helpful to provide the doctor with written examples of your child's behavior to show their need for 24/7 supervision to prevent injury.

• Sample IHSS Hazard Log for Protective Supervision: Use this fillable template to log times when your child injured themselves or you had to intervene to prevent injury. This kind of documentation can help support your request for protective supervision hours.

• Sample IHSS Paramedical Services Log: When applying for IHSS paramedical service hours, it is often helpful to provide your doctor with a spreadsheet of each paramedical service they have ordered, about how long it takes you to perform the task, and how frequently it occurs.

• Printable Worksheet to Audit Your Health Plan Coverage: It's important to review your insurance benefits and make sure you understand what your health plan covers so that you can get the most out of your plan benefits. This worksheet walks you through all the key elements to know, including deductible, therapy session limits, appeals, and more.

• Insurance Claim Tracker Spreadsheet Template: If you need a way to keep track of your superbills and their reimbursement status, check out this insurance spreadsheet template.

• Sample Cover Letter for Network-Level Reimbursement: If you are asking your health plan to reimburse you at the in-network level for an out-of-network provider, this sample cover letter can help you draft your request.

• Sample Template to Request Letter of Medical Necessity and Prescription: If you need to document medical necessity for a service or piece of equipment that you want insurance to cover, you'll need to request it from your child's provider.

• Provider Appointment Prep Sheet and Checklist: Before a doctor's appointment or visit to a therapy provider, make a written list of questions that you want to ask and any documents you need to bring. You can use this printable template to organize your notes for the appointment.

• Printable List of Questions to Ask an ABA Provider: Interviewing a potential provider is an important first step to see if they are a good fit for your child and family. Here's a list of questions you can ask the ABA provider you're interviewing, with room to take notes.

• Printable "About Me" Template for Hospital Room: If your child is going to be in the hospital for an extended period of time, creating a comfortable environment can make all the difference for you, your child, hospital staff, and visitors. First of all, make sure everyone who walks into the room knows your child’s name, what they like, and any important medical information.

Be sure to check out our education and IEP template library as well for sample letters, communication log templates, printable safety plans, and much more!