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How to fill out the Decision Form online
Filling out the Decision Form is a crucial step in the Surrogate Decision Making Program. This guide will walk you through each section of the form, ensuring you complete it accurately and efficiently for online submission.
Follow the steps to successfully complete the Decision Form online.
- Click ‘Get Form’ button to access the Decision Form and open it in your online editor.
- Begin by entering the facility name, vendor number, and county in the designated fields. Ensure all information is typed or printed clearly.
- Provide the individual's name, age, date of birth, sex, social security number, and Medicaid number. Use the categories provided to indicate ethnicity and religion.
- Select the marital status of the individual from the options provided, and describe the primary language they communicate in.
- Indicate the method of communication the individual uses from the detailed list. Choose the option that best describes their communication ability.
- Enter the number of living and known relatives, including children, siblings, and parents. Also, specify the number of actively involved family members.
- Complete the diagnosis section by entering the primary diagnosis, including the relevant ICD-9-CM code. Note any current medical and psychiatric diagnoses, along with their respective codes.
- Provide information on cognitive functioning by entering the IQ score if available, or the social composite score. Also, select the appropriate adaptive behavior level.
- Indicate the level of care required by circling the appropriate option provided in the form.
- Complete the functional assessment section based on the individual's status during the past four weeks. Mark the most accurate descriptions of their mobility and sensory/perceptual status.
- Once all sections are complete, ensure you review the form carefully for any errors. You can then save changes, download, print, or share the form as needed.
Start completing the Decision Form online today to facilitate the Surrogate Decision Making Program.
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