Get Request And Justification For Skilled Nursing Visits And - Mass

This guide provides comprehensive, step-by-step instructions for filling out the Request And Justification For Skilled Nursing Visits And - Mass form online. By following these guidelines, you will effectively complete the necessary sections to ensure your request is processed efficiently.

Follow the steps to successfully complete your form

1. Press the ‘Get Form’ button to access the document and open it in your designated editor.
2. Begin by entering the general information in Section I. This includes the member’s name, MassHealth ID number, and telephone number. Additionally, provide any other insurance information, if applicable, and explain why the service is not covered by other insurance.
3. In the Household Information subsection, specify the primary caregivers' names and relationships to the member. Indicate any recent changes in the member's status that may require further caregiver training.
4. For the Patient Assessment and Summary in Section II, fill in details including the date of birth, weight, height, primary medical diagnosis, and any secondary medical diagnoses. Describe the member's current medical status and ability to perform self-care and activities of daily living.
5. If requesting home health aide services, proceed to Section III. Rate the member's functional abilities across several categories, such as cognitive skills, toileting, eating, bathing, and ambulation. Be clear and specific in your assessments.
6. In Section IV, check all health-related services currently provided to the member, detailing the frequency and payer for each service.
7. Section V requires you to list any services from other agencies that the member is receiving, along with the frequency of those services and the contact details of the case manager.
8. For Section VI, clearly outline the request for skilled nursing and home health aide visits, including the time frame, number of visits, and any current MassHealth prior authorization details.
9. Finally, complete Section VII by entering the home health agency's name, address, and telephone number. Ensure the necessary signatures from the home health agency nurse and the physician are included, along with the date.
10. Once you have filled out all sections, review the completed form for accuracy. Save your changes, and choose to download, print, or share the document as needed.

Begin filling out your Request And Justification For Skilled Nursing Visits And - Mass form online today to ensure your needs are met.