Get Dysphagia Consultation Including Mbss And Esophageal 2020-2025

Completing the Dysphagia Consultation Including MBSS and Esophageal Evaluation Order Form is a crucial step in ensuring that patients receive the appropriate evaluations and treatments for swallowing difficulties. This guide provides clear instructions on each section of the form to help users complete it accurately and efficiently.

Follow the steps to successfully fill out the Dysphagia Consultation form

1. Press the ‘Get Form’ button to download the Dysphagia Consultation Including MBSS and Esophageal Evaluation Order Form. Open the form in your preferred online document editor.
2. Fill in the facility name. Indicate whether it is a skilled nursing facility or an assisted living facility. Complete the facility address, including city, state, and phone number.
3. Provide patient information, including their name, date of birth, sex, social security number, and their unit or room number. Additionally, input the patient's height and weight.
4. Complete the consent authorization section. Ensure that verbal consent is documented, noting from whom consent was received and capturing the signature and printed name of the staff member.
5. In the insurance coverage section, select the appropriate Medicare or Medicaid options and fill in the corresponding policy numbers and prior authorization numbers if applicable.
6. Detail the reasons for the consultation, ensuring you check all relevant boxes that pertain to the patient’s condition or symptoms.
7. Provide additional information regarding patient needs, such as any specific concerns related to breathing, feeding difficulties, or scheduling restrictions.
8. Fill out the medical history section, selecting all conditions that relate to the patient's dysphagia. Include any known food allergies and contact precautions if applicable.
9. Document current speech therapy status and pulmonary status, checking the relevant boxes pertaining to the patient's situation.
10. Indicate the current diet and consistencies, including specific foods and liquids being consumed, or note if the patient is NPO (nothing by mouth).
11. Detail the dentition status and cognitive abilities of the patient, completing the respective sections with the appropriate selections.
12. Complete the consultation order form by printing the name, NPI, and signature of the ordering physician, nurse practitioner, or physician assistant, along with the date.
13. Review the completed form for accuracy. Once finished, fax the form and a copy of the patient’s face sheet to the provided fax number. Retain a copy for the patient's permanent medical record.

Start completing the Dysphagia Consultation Including MBSS and Esophageal form online today.