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Get Long Term Care Professional Medical Information

The functional needs assessment is used to determine if the client meets the nursing facility, ICF/MR or hospital level of care. As a part of the functional needs assessment, a licensed medical professional shall complete this form to certify the client s medical necessity for long term care services. Client Information Section Last Name: First Name: Middle Initial: Street Address: Date of Birth: City: State: Telephone: Medical Information Section ICD 9 ICD 9 Description Code Onset Male.

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