Get Form122 Dc Final 6-24-2009.doc - Scdhhs

Filling out the Form122 DC Final 6-24-2009.doc is essential for individuals looking to access adult day health care services. This guide provides clear instructions to help users navigate the form effectively.

Follow the steps to fill out the Form122 DC Final 6-24-2009.doc with ease.

1. Click the ‘Get Form’ button to obtain the document and open it in your preferred editor.
2. Enter the participant’s name in the designated field at the top of the form.
3. Provide the social security number, ensuring it is correctly formatted with dashes (XXX-XX-).
4. Indicate the primary and secondary diagnoses in the respective fields.
5. Fill in the Medicaid number in the appropriate section.
6. State the date of birth in the specified format.
7. Document the medical history, detailing any pertinent medical information.
8. Complete the physical examination section by checking the relevant boxes for temperature, pulse, respiration, blood pressure, and any specific findings.
9. Enter laboratory data for the following categories: EENT, respiratory, cardiovascular, gastrointestinal, genitourinary, musculoskeletal, skin, and endocrine.
10. List any known allergies in the designated field.
11. Specify dietary requirements if applicable.
12. Outline any special care requirements, including any daily activity limitations or special therapies.
13. Indicate whether the individual is capable of self-administering their own medications by checking the appropriate box.
14. List any medications, including dose, frequency, and route of administration.
15. Physician must attest to the medical necessity of the services by signing and dating the form.
16. The adult day health care staff should sign and indicate the date sent.
17. Once all fields are completed, save your changes, and choose to download, print, or share the form as needed.

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