Get 1 Safety Determination Request Form- 102014 - Tn

Completing the Safety Determination Request Form is a critical step for entities seeking a safety determination in accordance with TennCare rules. This guide will provide clear and concise instructions on how to accurately fill out the form online.

Follow the steps to successfully complete the form online.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Fill in the applicant's name, Social Security Number (SSN), and date of birth (DOB) in the provided fields. Ensure that this information is accurate, as it will be used throughout the application process.
3. Complete the current living arrangements section. Indicate the applicant's residence by choosing from the options provided, such as living alone or with family members. Include any relevant details about their housing status, especially if they currently reside in a nursing facility.
4. Provide justification for the safety determination request. This includes selecting applicable justifications based on the applicant’s acuity scores and detailing how the lack of assistance may impact their safety.
5. For each justification checked, provide a detailed description explaining how safety is a concern for the applicant. Attach any supporting documentation as indicated, labeling each attachment accordingly.
6. Fill out the section for recent falls if applicable. Record details for each fall incident, including the location, circumstance, and any injuries sustained. Describe preventive measures that were in place and their effectiveness.
7. Complete the submitting entity attestation. Ensure that the form is signed by a licensed professional who has reviewed all the information provided. This signature is vital for the verification process.
8. Review the entire form to ensure all sections are accurately completed and all necessary documentation is attached. An incomplete form may lead to denial of the request.
9. Save changes to the form upon completion, and download or print a copy for your records before submitting it as required.

Take the necessary steps today to fill out the 1 Safety Determination Request Form online and ensure that all required documentation is prepared.