Get Medical Evaluation Of Applicant For Level Of Care Admission.doc. Forms And Publications - Dhs Ri

Completing the Medical Evaluation Of Applicant For Level Of Care Admission.doc is an essential step in assessing an individual's suitability for admission to a skilled nursing facility, assisted living, or community-based services. This guide provides a clear and structured approach to filling out the form accurately and comprehensively.

Follow the steps to complete the form effectively.

1. Use the ‘Get Form’ button to access the Medical Evaluation Of Applicant For Level Of Care Admission.doc, opening it in the appropriate document editor.
2. Fill in the Provider Medical Statement section with the necessary details including the date, applicant's name, social security number or medical identification number, address, city or town, state, and zip code.
3. Indicate the current living arrangement of the applicant and their date of birth. Specify the applicant's gender and if they live alone or with others.
4. Record the name of the facility the applicant is associated with, along with the date they were admitted.
5. Provide a detailed diagnosis, including both medical and behavioral issues, without using diagnosis codes. Include the primary and other diagnoses with their onset dates.
6. Assess and denote the prognosis of rehabilitation potential, indicating whether there is a permanent disability.
7. List any surgeries or infections experienced by the applicant, including specific dates.
8. Document any medications the applicant is currently taking, including dosage, frequency, and administration route.
9. Outline the present treatments and their frequency, including orders for diet, physical therapy, occupational therapy, speech therapy, oxygen needs, and any other pertinent therapeutic interventions.
10. Complete the section on Current Functional Activities by referring to the Code Key to indicate the level of assistance required for various tasks such as dressing, bathing, and medication management.
11. Evaluate the applicant's cognitive status, including awareness of their condition and ability to make decisions. Record scores from assessments like MMSE or BIMS.
12. Conclude by filling out the provider’s name, obtaining the signature, and dating the form to affirm completion.
13. Once all sections are filled, save your changes and choose to download, print, or share the completed form as necessary.

Complete and submit the Medical Evaluation Of Applicant For Level Of Care Admission.doc online today to ensure timely processing of your application.