F-11136 - Personal Care Addendum
Download a blank fillable F-11136 - Personal Care Addendum in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete F-11136 - Personal Care Addendum with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
HFS 107.13(2), Wis. Admin. Code
F-11136 (10/08)
FORWARDHEALTH
PERSONAL CARE ADDENDUM
Instructions: Print or type clearly. Refer to the Personal Care Addendum Completion Instructions, F-11136A, for information on
completing this form.
SECTION I — PROVIDER INFORMATION
1. Name — Provider
2. Provider Number
SECTION II — MEMBER INFORMATION
3. Name — Member
4. Member Identification Number
SECTION III — GENERAL ASSESSMENT
5. Skilled Visits Required by Member (Check all that apply.)
Registered Nurse
Physical Therapist
Licensed Practical Nurse
Occupational Therapist
Home Health Aide
Speech-Language Pathologist
6. Communication Capability (Check one.)
Communicates needs verbally.
Communicates verbally with difficulty, but can be understood.
Communicates with sign language, symbol board, written messages, gestures, or interpreter.
Communicates inappropriate content, makes garbled sounds.
Does not communicate needs.
Child with age-appropriate communication.
7. Hearing Aid Usage
Does the member wear a hearing aid?
Yes
No
If yes, what is the member’s ability to hear with the hearing aid, if customarily worn? (Check one, if applicable.)
No hearing impairment.
Hearing difficulty at level of conversation.
Hears and understands only very loud sounds (e.g., person speaking to member must yell to be heard.)
No useful hearing; unable to interpret audible sounds.
Not determined.
8. Vision Correction
Does the member wear corrective lenses?
Yes
No
If yes, what is the member’s ability to see with corrective lenses, if customarily worn? (Check one, if applicable.)
Has no impairment of vision.
Has difficulty seeing at level of print, but may be able to read large or thick print.
Has difficulty seeing obstacles in environment.
Has no useful vision.
Not determined.
Continued
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal