Get DMA372-124

NC DMA Long Term Care FL2 Form Recipient Information DMA372-124 1. Recipient Last Name 2. First Name 3. Recipient DOB 4. Recipient ID 5. Recipient Gender 6. SSN 7. Admission Date current location 8. Facility Name 9. PASRR 10. Facility Address 11. Provider Number 12. Attending Physician Name/Address 13. Relative Name/Address 14. Current Level of Care Home SNF ICF Hospital Dom Other 15. Requested Level of Care Vent Care Nursing Facility NF Rehab Spec* Hosp Rehab Extended Care OOS NF OOS Vent CAP/CH SNF CAP/CH Hosp CAP/DA SNF CAP/DA ICF 16. Discharge Plan Diagnosis Information Admitting Diagnosis code AND description xxx Date of Onset Primary x Patient Information Disoriented Constantly Intermittently Inappropriate Behavior Wanderer Verbally Abusive Injurious to Self Injurious to Others Injurious to Property Other Personal Care Assistance Bathing Feeding Dressing Total Care Physician Visits 30 Days Over 180 Days Special Care Factors Blood Pressure Diabetic Urine Testing PT by licensed PT Range of Motion Exercises Ambulatory Status Ambulatory Semi-Ambulatory Functional Limitations Sight Hearing Speech Contractures Activities Social Passive Active Group Participation Re-Socialization Family Supportive Neurological Convulsions/Seizures Grand Mal Petit Mal Frequency X-ray and Laboratory Findings/Date Bladder Continent Incontinent Indwelling Catheter External Catheter Communication of Needs Verbally Non-Verbally Does Not Communicate Skin Normal Decubiti Describe Bowel Bladder Program Restorative Feeding Program Speech Therapy Restraints Medications Name Strength Dosage and Route Bowel Colostomy Respiration Tracheostomy O2 PRN Cont Nutrition Status Diet Supplemental Spoon Parenteral Nasogastric Gastronomy Intake and Output Force Fluids Weight Additional Information Physician s Signature Date Fax this form to CSC at 855 710-1964 Instructions for completing this form can be found at http //www. Recipient DOB 4. Recipient ID 5. Recipient Gender 6. SSN 7. Admission Date current location 8. Facility Name 9. PASRR 10. Facility Address 11. Provider Number 12. Attending Physician Name/Address 13. Relative Name/Address 14. PASRR 10. Facility Address 11. Provider Number 12. Attending Physician Name/Address 13. Relative Name/Address 14. Current Level of Care Home SNF ICF Hospital Dom Other 15. Requested Level of Care Vent Care Nursing Facility NF Rehab Spec* Hosp Rehab Extended Care OOS NF OOS Vent CAP/CH SNF CAP/CH Hosp CAP/DA SNF CAP/DA ICF 16. Current Level of Care Home SNF ICF Hospital Dom Other 15. Requested Level of Care Vent Care Nursing Facility NF Rehab Spec* Hosp Rehab Extended Care OOS NF OOS Vent CAP/CH SNF CAP/CH Hosp CAP/DA SNF CAP/DA ICF 16. Discharge Plan Diagnosis Information Admitting Diagnosis code AND description xxx Date of Onset Primary x Patient Information Disoriented Constantly Intermittently Inappropriate Behavior Wanderer Verbally Abusive Injurious to Self Injurious to Others Injurious to Property Other Personal Care Assistance Bathing Feeding Dressing Total Care Physician Visits 30 Days Over 180 Days Special Care Factors Blood Pressure Diabetic Urine Testing PT by licensed PT Range of Motion Exercises Ambulatory Status Ambulatory Semi-Ambulatory Functional Limitations Sight Hearing Speech Contractures Activities Social Passive Active Group Participation Re-Socialization Family Supportive Neurological Convulsions/Seizures Grand Mal Petit Mal Frequency X-ray and Laboratory Findings/Date Bladder Continent Incontinent Indwelling Catheter External Catheter Communication of Needs Verbally Non-Verbally Does Not Communicate Skin Normal Decubiti Describe Bowel Bladder Program Restorative Feeding Program Speech Therapy Restraints Medications Name Strength Dosage and Route Bowel Colostomy Respiration Tracheostomy O2 PRN Cont Nutrition Status Diet Supplemental Spoon Parenteral Nasogastric Gastronomy Intake and Output Force Fluids Weight Additional Information Physician s Signature Date Fax this form to CSC at 855 710-1964 Instructions for completing this form can be found at http //www. .