MEDICAL CERTIFICATION FOR MEDICAID LONG-TERM CARE SERVICES AND PATIENT TRANSFER FORM
DOB:
Patient Name:
O. VITAL SIGNS
T. SKIN CARE – STAGE & ASSESSMENT
Pressure Ulcers
Time Taken:
Date:
(Indicate stage and location(s) of
WT:
HT:
lesions using corresponding number:
Temp:
BP:
1.
HR:
RR:
Sp02:
P. PATIENT HEALTH STATUS
2
Bladder:
Continent
Incontinent
3.
Ostomy
Catheter Type:
date inserted:
Foley Catheter:
List any other lesions or wounds:
Yes
No
If yes, date inserted:
Indications for use:
Urinary retention due to:
Monitoring intake and output
U. MENTAL / COGNITIVE STATUS AT TRANSFER
Skin Condition:
Alert, oriented, follows instructions
Other:
Alert, disoriented, but can follow simple instructions
Attempt to remove catheter made in hospital?
Yes
No
Alert, disoriented, and cannot follow simple instructions
Date Removed:
Not Alert
Bowel:
Continent
Incontinent
Ostomy
V. TREATMENT DEVICES
Date of Last BM:
Heparin Lock - Date changed:
Immunization status:
IV / PICC / Portacath Access - Date inserted:
Influenza:
Yes
No
Date:
Type:
Pneumococcal:
Yes
No
Date:
Internal Cardiac Defibrillator
Pacemaker
Q. NUTRITION / HYDRATION
Wound Vac
Dietary Instructions:
Other:
Respiratory - Delivery Device:
CPAP
BiPAP
Tube Feeding:
G-tube
J-tube
PEG
Nebulizer
Other:
Nasal Cannula
Insertion Date:
Supplements (type):
Mask: Type
TPN
Other Supplements:
Oxygen - liters:
%
PRN
Continuous
Self
Assistance
Difficulty Swallowing
Eating:
Trach Size:
Type:
Ventilator Settings:
R. TREATMENTS AND FREQUENCY
Suction
PT - Frequency:
W. PERSONAL ITEMS
OT - Frequency:
Artificial Eye
Prosthetic
Walker
Speech - Frequency:
Contacts
Cane
Other
Dialysis - Frequency:
Eyeglasses
Crutches
S. PHYSICAL FUNCTION
Dentures
Hearing Aids
Ambulation:
Transfer:
U
L
Partial
L
R
Not ambulatory
Self
X. COMMENTS (Optional)
Assistance
Ambulates independently
Ambulates with assistance
1 Assistant
2 Assistants
Ambulates with assistive device
Devices:
Weight-bearing:
Wheelchair (type):
Left:
Appliances:
Full
Partial
None
Signature:
Prosthesis:
Right:
Printed Name:
Lifting Device:
Full
Partial
None
Y. PHYSICIAN CERTIFICATION
I certify the individual requires nursing facility (NF) services.
The individual received care for this condition during hospitalization.
Rehab Potential (check one)
I certify the individual is in need of Medicaid Waiver Services in lieu of nursing facility placement.
Good
Fair
Poor
Effective date of medical condition
Date:
Physician/ARNP Signature:
Phone Number:
Printed Physician/ARNP Name & Title:
Date:
Person completing form:
Phone Number:
AHCA Form 5000-3008, ________________ (incorporated by reference in Rule 59G-1.045, F.A.C.)
revised October 2015
1
2
Form Dhmh 4241 (ssi/ltc) - Notice To Review Medical Assistance Eligibility For Ssi Long Term Care
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Form N-648 - Medical Certification For Disability Exceptions - U.s. Department And Immigration Services
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