Follow the steps to successfully complete your form.

1. Click ‘Get Form’ button to obtain the Long Term Care Medical Assessment form and open it in the editor.
2. Begin by filling out the 'General Patient Information' section. Ensure complete patient identifying information, such as the name and Medicaid number or Social Security Number, is accurately entered.
3. Proceed to enter contact information, including the patient's mailing address and telephone contact number. Confirm that all details are correct to ensure effective communication.
4. Move on to the 'General Facility or Agency Information' section. Provide the facility’s name, Medicaid provider number, and National Provider Identifier (NPI).
5. In the 'Nursing Facility Admissions Information' part, indicate the type of admission (initial, continued stay, re-admission, or transfer) and fill in the admit date. Check the sources accordingly.
6. Advance to the 'Medical Assessment' section. List the patient's medical diagnosis per line and provide a medication list, including name, method of administration, and frequency.
7. Complete the 'Nursing Services Related to Diagnosis', indicating any assistance the patient requires for daily activities. This includes checking for related services such as physical or occupational therapy.
8. Sign the form by entering the physician’s name, signature, date, and contact information, ensuring it reflects the patient's treatment accurately.
9. Before submitting, review the form to ensure all required sections are completed and accurate. You can save changes, download, print, or share the form as necessary.

Start completing your Centennial Care form online today to ensure timely processing.