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Get MN DHS-6249-ENG 2010

PROVIDER NPI SERVICE TYPE ACTUAL LEVEL OF CARE PROVIDED SERVICE(S) RECIPIENT IS RECEIVING OR REFERRED TO REASON FOR VARIANCE (if applicable) I. Risk of Harm l 1. Minimal l 2. Low l 3. Moderate l 4. Serious l 5. Extreme IV-B. Recovery Environment – Level of support l 1. Highly Supportive l 2. Supportive l 3. Limited Support l 4. Minimal Support l 5. No Support II. Functional Status l 1. Minimal l 2. Mild l 3. Moderate l 4. Serious l 5. Severe V. Treatment and Recover.

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