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Below are suggestions for completing the
form. This sheet is for informational purposes only and is not an
exact replica of the form. Forms are sometimes revised, so please
check to see if the item #'s match up when using the information in this
guide.
(Physician’s
Recommendation Concerning Skilled Nursing Home Care, Intermediate Care or
Intermediate care for the Mentally Retarded)
Don’t be intimidated by this form. It is the same form that is used
to determine whether people are eligible for nursing homes, but it in no way
means that your child will have to go into a nursing home. Deeming Waivers
just use this form to document the child’s medical needs.
Here is a step-by-step way of completing this medical form:
1. Facility’s Name and Address
Put in the local DFCS office and their address
Put the county that you live in where it says county ________
2. Leave this blank unless your child has Medicaid in months that only have
4 Fridays and not in months that have five Fridays.
3. Social Security Number
Put your child’s social security number
If your child does not have one, apply for one when you call Social Security
to get
your denial.
If it has been applied for but not received, put Applied For
4. Sex – Male or Female
4a. Birthdate – Specify by Month/Day/Year
5. Only one box will be checked
1. Nursing Facility – if your child has significant medical problems that
require close monitoring (example: oxygen, respirator, or heart monitor,
etc. If your child is dependent for assistance in daily care (eating,
dressing, toileting, bathing) and has some medical concerns such as
seizures, or a shunt that needs monitoring, check this box.
2. ICF/MR – Intermediate Care for the Mentally Retarded – If your child has
mental retardation or is significantly developmentally delayed and needs
therapies (OT, PT, Speech) and special education to meet his/her needs,
check this box.
6. Type of Recommendation – Mark Initial
7. Patient’s Name – Put your child’s name … Last name, First name,
Middle Initial
8. Date of Nursing Home Admission – LEAVE THIS BLANK
9. Patient Transferred from: LEAVE THIS BLANK
9A and 9B LEAVE BLANK
Under #5 and #6 there is space to write your address and phone number.
Also write the mother’s maiden name in the space allowed.
Date of Medicaid Application: LEAVE THIS BLANK
10. A parent must sign this. It only has to be one parent.
11. Date: DO NOT DATE THIS. LET THE DFCS WORKER DATE IT WHEN THE FORM IS
READY TO BE MAILED TO ATLANTA.
12. Diagnosis:
Primary
Secondary
Other
List all problems:
examples:
seizure disorder
cerebral palsy
mental retardation
visual impairment
speech delay
chronic respiratory infections
If you know the medical terminology, use it. It can make it more specific.
Example: cerebral palsy, spastic quadriplegia
If you have more than three, continue it in #13 where it has extra space
13. Treatment Plan
Write in (see attached). This will refer to the Individual Habilitation Plan
Hospital Diagnoses – leave this blank
Medications
Name
Dosage
Route
Frequency
List all medications ____mg by mouth 2 x day
By injection 4 x day
Diagnostic and Treatment Procedures
List all tests that the doctors run and how often (every three months or as
needed)
CT Scan
MRI
EEG
EKG
Lab Work – Blood Levels for Seizure Medication
List therapy the child receives and how often (3 times per week or 2 hours
per week)
Speech therapy
Occupational therapy
Physical therapy
Adaptive Physical Education
14. Check the one that best describes the child’s needs:
Skilled Care – very involved nursing care (oxygen, monitors, etc)
Intermediate – needs lost of assistance in daily living…some medical
problems (seizures, shunt, etc)
Intermediate Care for the Mentally Retarded – for people with mental
retardation who need lost of assistance with daily living and judgment of
safety…can also include behavior problems
15. Check Permanent
16. Check Yes
17. Check the box by “could” and by “community care” and “home health
services.” This is stating that the child’s needs are more significant than
could be met by occasional visit from a nurse or nursing aide. It takes into
account all the supports that families provide in caring for their child.
18. Have the doctor sign here.
Choose the doctor that is most convenient or who knows your child best.
19. Fill in the doctor’s name and address.
20. Date: Again Do Not Date it. The DFCS Worker will date it when she is
ready to mail the form. The form is only good for 60 days so that way there
will be maximum time for processing.
21. Doctor fill in his/her License number and phone number.
You might get the doctor’s nurse to fill in the license number.
22. What kind of diet?
Check the one that fits…If it is not listed put other and write in the kind
of diet…for example pureed or specify that the child has a difficult time
with meat textures.
23. Is the child toilet trained for Bowel Movements?
If he/she is, check Continent
If he/she has some accidents, check occas. Incontinent
If he/she is not trained and wears diapers, check incontinent
If he/she has a colostomy, check colostomy.
24. Overall condition
If the child is doing okay, check stable.
If the child’s health is up and down, check fluctuating.
If the health issues are getting worse, check deteriorating.
If the child’s health condition is serious, check critical.
If the child has a terminal illness, check terminal.
25. Restorative Potential
This refers to the child’s potential to be completely without problems.
Usually do not mark above fair.
26. Mental and Behavioral Status
These are words that describe the child. Mark all the ones that apply
27. Decubiti – This refers to bed sores.
Usually this is marked no.
Some kids who sit in wheelchairs all day have some skin breakdown.
If this is the case mark, yes.
28. Is the child toilet trained for urination?
If the child is toilet trained, check continent.
If the child has some accidents, check occas. Incontinent.
If the child is not toilet trained and wears diapers, check incontinent.
If the child is catheterized, check catheter.
29. How many hour a day is the child out of bed?
If the child needs any of the items listed, check the ones that are used.
30. How many times per week does your child receive these and how many times
they really need the service?
Physical therapy
Occupational therapy
Remotive therapy – Don’t use this category
Reality Orientation – Don’t use this category
Speech therapy
Bowel and Bladder Retrain – Don’t use this category
Active Program – If your child is in a day program or an educational class
put
how many times per week he/she attends.
If a person works with your child in the home, specify how
often the person comes per week.
31. Impairments
Sight
Hearing
Speech
Limited Motion
Paralysis
Mark the boxes as follows: If the problem is severe, put a #1.
If the problem is moderate, put a #2
If the problem is mild, put a #3.
If there is not a problem in that area, put a #4.
Examples:
For a child who is deaf: For a child who has cerebral palsy:
Sight – 4 Sight – 4
Hearing – 1 Hearing – 4
Speech – 1 Speech – 3
Ltd Motion – 4 Ltd. Motion – 1
Paralysis – 4 Paralysis – 4
Activities of Daily Living
Eats
Wheelchair
Transfers (getting in and out of bed, or a wheelchair)
Bath
Ambulation (walking)
Dressing
Mark the boxes as follows:
If the person is dependent (needs someone to do it for them), check #1.
If the person needs assistance, check #2
Examples: Someone is needed to push the wheelchair.
Someone is needed to fix the person’s plate.
Someone is needed to run the water in the tub.
If the person is independent in these activities, check #3.
If the item does not apply to the person, check #4.
For example: If a person doesn’t use a wheelchair, mark #4 in the
Box for wheelchair.
32. Leave this blank.
33. Leave this blank.
34. Have the Doctor sign here, too.
35. Again, Do not date this form.
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A special needs
trust is the only estate planning option that protects assets, enables the
beneficiary to receive goods and services from the estate, and still
preserves eligibility for government benefits. |
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