Printable 3871 Maryland Medicaid Template

Level of Care/Services Requested (application for rehab

Application Date: ________________________

hospitals must be accompanied by a plan of care from admitting

Financial Eligibility Date:__________________

hospital) (Please check)

Social Security #:_________________________

Medical Assistance #:_____________________

 Chronic Hospital* Model Waiver*

Patient’s Last Name: ____________________________________

Patient’s First Name: _______________________

Patients Date of Birth: __________ Sex: ____Adm. Date: ________

Permanent Address: ____________________________________

_____________________________________________________

Name of Last Provider (Hospital, Long Term Care Facility)

Present location of Patient: (if different from above)

Institution: ___________________________________

______________________________________________________

Admission Date: _______________________________

______________________________________________________

Discharge Date: _______________________________

Patient’s Representative Name: ____________________________

Relationship to Patient: _________________________

Representative Phone #: __________________________________

Representative Address: ________________________

Is language a barrier to communication ability? ___YES ___NO

____________________________________________

DHMH 3871 rev. 4/95

Medical Review Form

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Part C: Functional Status (Use one of the following codes)

(If assistive device (e.g., Wheelchair, Walker) used, note functional ability while using device)

0.

Little or no difficulty (completely independent

2.

Limited physical assistance by caregiver

or setup only is needed

3.

Extensive physical assistance by caregiver

1.

Supervision/Verbal cuing

4.

Total dependence on others

___ Locomotion (if using adaptive/assistive device,

___ Dressing

Specify type): _____________________________

___ Bathing

___ Transfer bed/chair

___ Eating

___ Reposition/Bed mobility

Appetite (Check one): ___ Good ___ Fair ___ Poor

Bladder

Bowel

0

0

Complete control-or infrequent stress incontinence

1

1

Usually continent-accidents once a week or less

2

2

Occasionally incontinent- accidents 2+ weekly, but not daily

3

3

Frequently incontinent- accidents daily but some control present

4

4

Incontinent- Multiple daily accidents

*******************************************************************************************************

Part D: Cognitive/Behavioral Status

1. Memory/orientation

Y=Yes

N=No

2. Cognitive skills for daily life decision making and safety (Check one)

Yes

No

___

___

Can recall after 5 minutes

___

Independent decisions consistent and reasonable

___

___

Knows current season

___

Modified/some difficulty in new situations only

___

___

Knows own name

___

Moderately impaired/decisions requires cues/supervision

___

___

Can recall long past events

___

Severely impaired/rarely or never makes decisions

___

___

Knows present location

___

___

Knows family/caretaker

3. Communication

0- Always

1-Usually

2-Sometimes 3-Rarely

Ability to understand others

_____

_____

_____

____

Ability to make self understood

_____

_____

_____

____

Ability to follow simple commands

_____

_____

_____

____

DHMH 3871 rev. 4/95

Medical Review Form

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Patient’s Name ____________________________________

4. Behavior issues (enter one code from A and B in the appropriate column)

A. Frequency

B. Easily Altered

1= Occasionally

1= Yes

2=Often, but not daily

2= No

3= Daily

Description of Problem Behaviors

A

B

Age Appropriate

Functioning Level

Adaptive Equipment

Cognition

Wheelchair

Social Emotional

Splints/Braces

Behavior

Side Lyer

Communications

Walker

Gross Motor Abilities

Adaptive Seating

Fine Motor Abilities

Communication Devices

Feeding

Other

Toileting

Self Care

Part F: Physician’s Certification for Level of Care

This patient is certified as in need of the following services (Check One):

Chronic Hospital

Model Waiver

Renewal

___ Medical Eligibility Established

MD Advisor ___

___Medical Eligibility Established

MD Advisor___

___ Medical Eligibility Denied

___ Medical Eligibility Denied

Effective Date: _____________________

Effective Date: _____________________

Type of Service: _________________________________

Type of Service: __________________________________

Certificate Period: From: _____________ To: ___________

Certificate Period: From: _____________ To: ___________

Agent Signature: _________________________________

Agent Signature: __________________________________

Date: ___________________________________________

Date: ___________________________________________

DHMH 3871 rev. 4/95

Medical Review Form

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