Www.deemingwaiverhelp.com Sample Packet for a primary diagnosis of Autism.
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Www.deemingwaiverhelp.com Sample Packet for a primary diagnosis of Autism.
Www.deemingwaiverhelp.com Sample Packet for a primary diagnosis of Autism. Level of Care: ICF/MR (Intermediate Care Facility/Mental Retardation) Your packet should contain: 1. 2. 3. 4. A cover letter outlining what's in your packet and a picture of your child. Financial Summary (Medicaid Form 94 – you may have done this online) Copies of last 2 check stubs and bank statements DMA 285 – Insurance Form and copy of insurance card And the Medical side of it – with forms signed by the doctor 5. DMA 6A (Crazy Box Form) 6. DMA 6A Attachment 1: Medical History 7. DMA 6A Attachment 2: Prescription list (includes dosage and frequency) 8. Other attachments that won't fit in the boxes on the forms (diagnoses, treatments, etc.) 9. DMA 706 Letter of Medical Necessity and Care Plan 10. DMA 704 Cost Effectiveness Form 11. Copy of latest psychological exam or developmental pediatrician report. Clearly mark (place a sticky note to the side) where test results point to below average in Adaptive (Self Care, Self Direction, Age Appropriate Ability to Live), Communication, Motor/Mobility scores. You need to have scores 2 standard deviations below the norm in 3 of these areas. 12. Copy of latest IEP. Clearly mark (place a sticky note to the side) where services outline the number of therapeutic sessions your child receives in the span of a week (how much SLP, OT, PT, Behavioral Support/Social Skills training). Combined with your private therapies, this total number of therapies should equal 5. 13. Copy of reports that verify diagnosis. 14. Copies of medical records – if this is your first time, throw in EVERYTHING you can find. If this is a subsequent year, include just last year's records. If this has been helpful, please consider making a donation to Southside Suport, Incorporated so we can continue to keep forms updated on the website. Www.southsidesupport.org. Southside Support, P. O. Box 812, Fayetteville, GA 30214. Email: [email protected] Last Modified: 10-29-12 Type of Program: PEDIATRIC DMA 6(A) Nursing Facility GAPP TEFRA/Katie Beckett PHYSICIAN’S RECOMMENDATION FOR PEDIATRIC CARE Section A – Identifying Information 1. Applicant’s Name/Address: 2. Medicaid Number: Your Childs Name Name: _____________________________________ initial application ____________________________ 3. Social Security Number 1233 Four Street Address: ___________________________________ 333-33-3333 4. Sex Age M/F 4A. Birthdate under 18 01-01-01 Cityville GA 30000 __________________________________________ Dr. Doctor 5. Primary Care Physician: _______________________________________________ Fayette DFCS County: ______________________________ 770-000-0001 6. Applicant’s Telephone # _______________________________________________ 7. Does guardian think the applicant should be institutionalized? Yes 8. Does child attend school? Yes No No Mom the Awesome Name of Caregiver #1: ____________________________________ 9. Date of Medicaid Application 12 01 12 _______/______/______ Dad the Fantastic Name of Caregiver #2: _______________________________________ I hereby authorize the physician, facility or other health care provider named herein to disclose protected health information and release the medical records of the applicant/beneficiary to the Georgia Department of Community Health and the Department of Human Services, as may be requested by those agencies, for the purpose of Medicaid eligibility determination. This authorization expires twelve (12) months from the date signed or when revoked by me, whichever comes first. 10. Signature: ____________________________________________________ (Parent or other Legal Representative) 12 01 12 11. Date: _____/_____/____ Section B – Physician’s Report and Recommendation 12. History: (attach additional sheet if needed) see attached sheet 13. Diagnosis Autism 1) _________________________ 2) __________________________ 3) _________________________ (Add attachment for additional diagnoses) 14. Medications 1. ICD 2. ICD 3. ICD 299.0 15. Diagnostic and Treatment Procedures Name Zoloft Dosage 10 ml oral Route Frequency 1 per day Type Frequency SLP 2X/Week OT 1X/week Behavior Therapy 5X/week 16. Treatment Plan (Attach copy of order sheet if more convenient or other pertinent documents) 1-01-01 Previous Hospitalizations: ___________________ Rehabilitative Services: _____________________ Other Health Services: ________________ Premature birth Hospital Diagnosis: 1) __________________________ 2) Secondary ____________________________ 3) Other _______________________ None 17. Anticipated Dates of Hospitalization: ________________ 18. Level of Care Recommended: Hospital Nursing Facility ■ IC/MR Facility 19. Type of Recommendation: 20. Patient Transferred from (check one): 21. Length of Time Care Needed ____ Months 22. Is patient free ■ Initial Hospital Another NF 1) ✔ Permanent of communicable Change Level of Care Private Pay Lives at home 2) Temporary________estimated diseases? Continued Placement Yes No 23. This patient’s condition ✔ could could not be managed by provision of Community Care or Home Health Services Dr. Doctor 24. Physician’s Name (Print): _____________________________________________________________________________ 1445 Big Hospital Lane, Cityville, GA 30000 Physician’s Address (Print): ___________________________________________________________________________ 25. I certify that this patient requires the level of care provided by a nursing facility, IC/MR facility, or hospital ______________________________________________________________________ Physician’s Signature 12 01 12 26. Date signed by Physician _____/_____/____ 222222 27. Physician’s Licensure No. _________________________________ 770-000-0002 28. Physician’s Telephone #: _________________________________ Page 1 of 2 Section C– Evaluation of Nursing Care Needed (check appropriate box only) 29. Nutrition 30. Bowel 31. Cardiopulmonary Status 32. Mobility 33. Behavioral S tatus Regular Age Dependent Monitoring Prosthesis Agitated Diabetic Shots Incontinence CPAP/Bi-PAP Splints Cooperative Formula-Special Incontinent - Age > 3 years CP Monitor Unable to ambulate > Alert Tube feeding Colostomy Pulse Ox 18 months old Developmental Delay N/G-tube/G-tube Continent Vital signs > 2/days Wheel chair Mental Retardation Slow Feeder Other ______________ Therapy Normal Behavioral Problems FTT or PrematureFrequent accidents Hyperal Oxygen IV Use Trach Medications/GT Nebulizer Tx Meds Suctioning Special Diet - Chest - Physical Tx GFCF Room Air 34. Integument System (please describe, if checked) Uses inserts for Home Ventankle pronation 35. Urogenital 36. Surgery Suicidal Hostile Autism - aggression and outbursts (tantrums), elopement 37. Therapy/Visits 38. Neurological Status Burn Care Dialysis in home Level 1 (5 or > surgeries) Day care Services Deaf Sterile Dressings Ostomy Level II (< 5 surgeries) High Tech - 4 or more Blind Decubiti Incontinent – Age > 3 years None times per week Seizures Bedridden Catheterization Low Tech – 3 or less Neurological Deficits Eczema-severe Continent times per week or MD Paralysis visits > 4 per month Normal Normal Frequent accidents Frequent eczema 39. Other Therapy Visits ■ Five days per week None 40. Remarks Less than 5 days per week N/A 41. Pre-Admission Certification Number: __________________________________ 12 01 12 42.Date Signed _____/____/____ Dr. Doctor 43. Print Name of MD or RN: ___________________________________________________________ Signature of MD or RN: ______________________________________________________________ DO NOT WRITE BELOW THIS LINE 44. Continued Stay Review Date: ____________ Admission Date: _____________ Approved for _________ Days or ___________ Months 45. Are nursing services, rehabilitative services or other health related services requested ordinarily provided in an institution? Yes No 46A. State Authority MH & MR Screening Level I/II Restricted Auth. Code Date 46B. This is not a re-admission for OBRA purposes 47. Hospitalization Precertification Restricted Auth. Code Met Not Met 48. Level of Care Recommended by Contractor Hospital Nursing Facility 49. Approval Period 50. Signature (Contractor) 51. Date ________________________________ _____/____/____ Page 2 of 2 Date IC/MR Facility 52. Attachments (Contractor) Yes No DMA-6A (11/2011) TEFRA/Katie Beckett Medical Necessity/Level of Care Statement Your Child's Name 01-01-01 333-33-3333 Member Name:_________________________ DOB: _______ SS#_______________ Autism 299.0 Diagnosis: ________________________________________________________________________________ _________________________________________________________________________________________ Recommended level of Care: ✔ Nursing facility level of care Hospital level of care Level of care required in an Intermediate Care Facility for MR (ICF-MR) Medical History: (May attach hospital discharge summary or provide narrative): See attached medical history (attached history should include prenatal history, early childhood development, and major surgeries and diagnoses. You can also __________________________________________________________________________________________ include dates of hospitalization, severe illnesses, or even a range of dates when chronic infections took place: 5 ear infections winter 2004 __________________________________________________________________________________________ ____________________________________ Current Needs Cardiovascular: Neurological: Respiratory: Nutrition: Integumentary: Urogenital: Bowel: Endocrine : Immune: Skeletal: Other: None ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ Description of Skilled Nursing Needs __________________________________________ Yearly EEG as needed for seizure review __________________________________________ Nebulizer for allergy attacks __________________________________________ GFCF Diet and supplementation __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ Behavioral therapy 5X weekly with ABA at school __________________________________________ 3 0 2 Therapy: Speech sessions/wk ____ PT sessions/wk ____ OT sessions/wk ____ (attach current notes) Hospitalizations within last 12 months: (Attach most recent hospital discharge summary) Date: _________ Reason: __________ Duration: __________________________ SLP and OT sessions done through school system - refer to IEP for goals and progress. No hospitalizations Comments: ______________________________________________________________ in past year. Last surgery 12/2006 for removal of adenoids/tonsils ________________________________________________________________________ YES 6 5 X (attach if in effect) Child in school: _____ Hrs per day _____ Days per wk ___ N/A ____ IEP/IFSP __ X Nurse in attendance during school day: _____ N/A ____(attach last month’s nursing notes) X Skilled Nursing hours received: Hrs./day ______ N/A ________ I attest that the above information is accurate and this member meets Pediatric Level of Care Criteria and requires the skilled care that is ordinarily provided in a nursing facility, hospital or facililty whose primary purpose is to furnish health and rehabilitative services to persons with mental retardation or related conditions. Physician’s Signature: __________________________ Primary Caregiver Signature: __________________________ 12-01-12 Date: ____________ 12-01-12 Date: ____________ ** Foster Care Applicants must have the signature of the DFCS representative. DMA – 706 Rev. 04/11 TEFRA/Katie Beckett Cost-Effectiveness Form (Child’s physician must complete Form) The following information is requested for the purpose of determining your patient’s eligibility for Medicaid: Patient’s Name:______Your Child’s Name______ Medicaid #:____Initial Application _______ Diagnosis:____Autism 299.0 ______________________________________________________ Prognosis:_______fair___________________________________________________________ Please provide the estimated monthly costs of Medicaid services your patient will need or is seeking for Medicaid to cover for in-home care: Physician’s services Durable medical equipment Drugs Therapy(s) Skilled Nursing Services Other(s)__behavior therapy____ $___200_________ _______________ ____90 (co-pay amount)_ ____800________ _______________ _____400_______ TOTAL $____1400_______ Will home care be as good or better than institutional care? _____X_____ Yes __________ No COMMENTS: Note, my child has primary insurance through his parents. It picks up a substantial portion of monthly costs. We anticipate Medicaid paying for co-pays, medication, deductible, and some dental and vision services only. PHYSICIAN’S SIGNATURE _______________________________________________________ DATE: ______________12-01-12_____________________________________________ DMA Form 704 Rev. 10-04