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Print Form Adult Care Home FL2 Form PRIOR APPROVAL UTILIZATION REVIEW ON-SITE REVIEW IDENTIFICATION 1. PATIENT S LAST NAME FIRST MIDDLE 5. COUNTY AND MEDICAID NUMBER 2. BIRTHDATE M/D/Y 6. FACILITY 3. SEX ADDRESS 8. ATTENDING PHYSICIAN NAME AND ADDRESS 11. RECOMMENDED LEVEL OF CARE 7. PROVIDER NUMBER 9. RELATIVE NAME AND ADDRESS 10. CURRENT LEVEL OF CARE 4. ADMISSION DATE CURRENT LOCATION HOME SNF ICF HOSPITAL DOMICILIARY REST HOME OTHER 14. DISCHARGE PLAN 13. DATE APPROVED/DENIED 15. ADMITTING DIAGNOSES PRIMARY SECONARDY DATES OF ONSET 16. PATIENT INFORMATION DISORIENTED CONSTANTLY INTERMITTENTLY INAPPROPRIATE BEHAVIOR WANDERER VERBALLY ABUSIVE INJUROUS TO SELF INJUROUS TO OTHERS INJUROUS TO PROPERTY OTHER AMBULATORY STATUS AMBULATORY SEMI-AMBULATORY FUNCTIONAL LIMITATIONS SIGHT HEARING SPEECH CONTRACTURES ACTIVITIES/SOCIAL PASSIVE PERSONAL CARE ASSISTANCE BATHING ACTIVE FEEDING GROUP PARTICIPATION DRESSING RE-SOCIALIZATION TOTAL CARE FAMILY SUPPORTIVE PHYSICAN VISITS NEUROLOGICAL 30 DAYS CONVULSIONS/SEIZURES GRAND MAL OVER 180 DAYS PETIT MAL FREQUENCY 17. SPECIAL CARE FACTORS BLOOD PRESSURE DIABETIC URINE TESTING PT BY LICENSED PT RANGE OF MOTION EXERCISES BLADDER CONTINENT INDWELLING CATHETER EXTERNAL CATHETER COMMUNICATION OF NEEDS VERBALLY NON-VERBALLY DOES NOT COMMUNICATE SKIN NORMAL DECUBITI-DESCRIBE SPECIAL CARE FACTORS BOWEL AND BLADDER PROGRAM RESTORATIVE FEEDING PROGRAM SPEECH THERAPY RESTRAINTS 18. MEDICATIONS/NAME STRENGTH DOSAGE ROUTE 19. X-RAY AND LABORATORY FINDINGS/DATE 20 ADDITIONAL INFORMATION 21. PHYSICIAN S SIGNATURE DATE BOWEL COLOSTOMY RESPIRATION TRACHEOSTOMY PRN CONT NUTRITION STATUS DIET SUPPLEMENTAL SPOON PARENTERAL NASOGASTRIC GASTROSTOMY INTAKE AND OUTPUT FORCE FLUIDS WEIGHT. PATIENT S LAST NAME FIRST MIDDLE 5. COUNTY AND MEDICAID NUMBER 2. BIRTHDATE M/D/Y 6. FACILITY 3. SEX ADDRESS 8. ATTENDING PHYSICIAN NAME AND ADDRESS 11. RECOMMENDED LEVEL OF CARE 7. PROVIDER NUMBER 9. RELATIVE NAME AND ADDRESS 10. ATTENDING PHYSICIAN NAME AND ADDRESS 11. RECOMMENDED LEVEL OF CARE 7. PROVIDER NUMBER 9. RELATIVE NAME AND ADDRESS 10. CURRENT LEVEL OF CARE 4. ADMISSION DATE CURRENT LOCATION HOME SNF ICF HOSPITAL DOMICILIARY REST HOME OTHER 14. CURRENT LEVEL OF CARE 4. ADMISSION DATE CURRENT LOCATION HOME SNF ICF HOSPITAL DOMICILIARY REST HOME OTHER 14. DISCHARGE PLAN 13. DATE APPROVED/DENIED 15. ADMITTING DIAGNOSES PRIMARY SECONARDY DATES OF ONSET 16. DISCHARGE PLAN 13. DATE APPROVED/DENIED 15. ADMITTING DIAGNOSES PRIMARY SECONARDY DATES OF ONSET 16. PATIENT INFORMATION DISORIENTED CONSTANTLY INTERMITTENTLY INAPPROPRIATE BEHAVIOR WANDERER VERBALLY ABUSIVE INJUROUS TO SELF INJUROUS TO OTHERS INJUROUS TO PROPERTY OTHER AMBULATORY STATUS AMBULATORY SEMI-AMBULATORY FUNCTIONAL LIMITATIONS SIGHT HEARING SPEECH CONTRACTURES ACTIVITIES/SOCIAL PASSIVE PERSONAL CARE ASSISTANCE BATHING ACTIVE FEEDING GROUP PARTICIPATION DRESSING RE-SOCIALIZATION TOTAL CARE FAMILY SUPPORTIVE PHYSICAN VISITS NEUROLOGICAL 30 DAYS CONVULSIONS/SEIZURES GRAND MAL OVER 180 DAYS PETIT MAL FREQUENCY 17. .

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