Get Medically Intensive Childrens Program Form

Completing the Medically Intensive Children’s Program Form is a crucial step in requesting skilled private duty nursing services for children aged 17 years and younger. This guide provides clear instructions to help you navigate each section of the form efficiently and effectively.

Follow the steps to fill out the Medically Intensive Children's Program Form.

1. Click the ‘Get Form’ button to access the Medically Intensive Children’s Program Form and open it for completion.
2. Begin by entering the date of application and the child's admission date to the hospital. Use the format MM/DD/YYYY.
3. Provide the child's full name, including last name and first name, and their date of birth in the specified format MM/DD/YY.
4. Fill in the contact information section, including the name of the hospital or referral source submitting the application, email address, and the name and telephone number of a contact person regarding the application.
5. Indicate the child's Medicaid number, which is mandatory for receiving MICP services, and provide the ADSA ID if known.
6. Answer whether a request for MICP nursing has been made in the past and specify if applicable, including the date.
7. Complete the section for parent(s)/guardian name and the family's primary language, selecting from the provided options.
8. In the placements recommendations section, specify if the child's needs can be met at home and detail any hours requested, along with the reasons for out-of-home placement if applicable.
9. List the child's diagnoses, including any developmental delays or health conditions.
10. Check all applicable funding sources for nursing care and provide detailed information about any private insurance coverage.
11. Complete the section regarding conditions supporting the request for MICP, checking all that apply and providing necessary explanations.
12. Check off all required documents and information that must accompany the application, ensuring all boxes are marked and all necessary attachments are included.
13. Sign and date the application as the parent or legal representative, confirming the request for MICP nursing services.
14. After filling out the form, save your changes and consider downloading or printing a copy for your records before submitting.

Complete your Medically Intensive Children’s Program Form online today to ensure timely processing of your application.