Get La Bhsf Form 90-l 2008

Filling out the LA BHSF Form 90-L online can streamline the process of requesting a medical eligibility determination. This guide provides clear, step-by-step instructions to assist users in filling out the form accurately and efficiently.

Follow the steps to successfully fill out the LA BHSF Form 90-L.

1. Press the ‘Get Form’ button to access the required form and open it in your preferred editor.
2. In the 'Recipient Information' section, fill in the recipient’s name, Social Security number, and Medicaid number as prompted. Ensure that the information is accurate.
3. Provide the complete address, including city, state, zip code, and parish, for both the recipient and the responsible party or curator. Include their phone number.
4. Indicate the recipient's race and Medicare number, and enter the date of birth in the specified format.
5. Detail the living arrangements by selecting from the options provided (own home, relative's home, or other). If applicable, list previous institutional care received, including the facility names and dates.
6. In the 'Home/Community-based Services' section, specify any services that have been used or considered, and provide reasons why services may not have been suitable.
7. Indicate whether you are requesting temporary or permanent nursing home placement.
8. Sign and date the form in the 'Applicant/Responsible Party Signature' section.
9. In the 'Level of Care Determination' section, select the appropriate level of care based on the recipient's needs as specified.
10. Answer the questions regarding the likelihood of requiring services in a medical facility and whether Home/Community Based Services are adequate.
11. Input the medical information in the relevant fields, including diagnosis, medications (with dosage and frequency), recent hospitalizations, and mental status.
12. Complete the 'Activities of Daily Living' and 'Special Care/Procedures' sections by checking the applicable options.
13. Fill in the physical examination details, including height, weight, and lab results.
14. Have the attending physician complete their section with their name, phone number, address, and signature, along with the date.
15. Once all sections are filled, ensure that all information is correct. You can then save changes, download, print, or share the form as necessary.

Complete the LA BHSF Form 90-L online today for a seamless application process.