Family Interview Form Page 7
ADVERTISEMENT
1
2
3
4
5
6
7
8DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
FAMILY INTERVIEW
Are you able to get money from [resident’s name]'s account at any time?
3)
No
Yes
Does the facility give you a statement of how much money is in the resident’s
4)
No
account?
Yes
[If the resident is on Medicaid], did the staff give her/him (or you) a list of
5)
No
services and items that you would and would not be charged for?
Yes
N/A, not a Medicaid resident
Admission Process QP183
O
Was the resident admitted within the past 9 months?
1)
No (skip to Notification of Change)
Yes
Did you participate in the admission process?
2)
No (skip to Notification of Change)
Yes
When [resident’s name] was admitted, did the staff tell you about how to
3)
No
apply for and use Medicaid or Medicare to pay for her/his stay?
Yes
Did the facility ensure that you (or another individual) would not have to
4)
No
make a payment out of your own pocket if, for some reason, the resident is
Yes
unable to pay from his/her own resources?
Did the facility inform you of the rights of residents in the facility?
5)
No
Yes
Notification of Change QP252
P
Are you the person who would be notified of a change in condition or an
1)
No (Interview is complete)
accident involving the resident?
Yes
Has there been a change in [resident’s name]'s condition within the past
2)
No (skip to #4)
several months?
Yes
Did the staff notify you promptly?
3)
No
Yes
FORM CMS-20049 (7/2012)
7
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business