Get Nc Dhhs Fl2 2018-2025

Filling out the NC DHHS FL2 form online is essential for individuals seeking prior approval for adult care services. This guide will walk you through each section of the form, ensuring that you can complete it accurately and efficiently.

Follow the steps to successfully complete the form online.

1. Click the ‘Get Form’ button to obtain the FL2 form and open it in your preferred online platform for editing.
2. Begin with the identification section: Enter the patient's last name, first name, and middle name.
3. Input the patient's birthdate in the format of month, day, and year.
4. Select the patient's sex from the options provided.
5. Provide the county and Medicaid number associated with the patient.
6. Fill in the facility's name and address where the patient is currently located.
7. Enter the attending physician's name and their address.
8. List the name and address of the relative contact.
9. Specify the current and recommended levels of care, choosing from options such as home, skilled nursing facility (SNF), intermediate care facility (ICF), hospital, domiciliary, or other.
10. Include the admission date to the current location.
11. Provide the provider number assigned to the facility.
12. Fill in the approval number if applicable.
13. Outline the discharge plan, indicating the preferred location after care.
14. Record the date the care was approved or denied.
15. Detail the admitting diagnoses, including primary and secondary conditions along with their dates of onset.
16. In the patient information section, mark any special considerations such as behavioral issues or required personal care assistance.
17. Indicate the ambulatory status of the patient (ambulatory, semi-ambulatory, or non-ambulatory).
18. Identify any functional limitations the patient may have.
19. Provide information regarding special care factors, which may include medication needs or communication capabilities.
20. List any medications prescribed, including name, strength, dosage, and route.
21. Note any x-ray and laboratory findings with corresponding dates.
22. Include any additional information relevant to the patient’s care.
23. Finally, ensure that the physician signs and dates the form to validate the information provided.

Complete your documents online to ensure a smooth application process.