Medically Frail Attestation & Referral Form Page 2
ADVERTISEMENT
1
2
3
4Please check ALL the appropriate boxes in the table that best defines the condition of the member.
Definition
Category
1. Individuals with disabling mental disorder
The member has a diagnosis of at least one of
the following:
psychotic disorder;
schizophrenia;
schizoaffective disorder;
major depression;
bipolar disorder;
delusional disorder
obsessive-compulsive disorder
2. Individuals with chronic substance use
Individuals with a chronic substance use disorder:
disorder
The member has a diagnosis of substance use
disorder,
AND
The member meets the severe substance
abuse disorder level on the DSM-V Severity
Scale by meeting 6 or more diagnostic
criteria,
OR
The member’s current condition meets the
medically-monitored or medically-managed
intensive inpatient criteria of the ASAM criteria.
(“DSM-V” means the 5th edition of the Diagnostic
and Statistical Manual of Mental Disorders
published by the American Psychiatric Association.
“ASAM criteria” means the 2013 edition of The
ASAM Criteria: Treatment Criteria for Addictive,
Substance-Related, and Co-Occurring Conditions
published by the American Society of Addiction
Medicine.)
The individual meets criteria for hospice
3. Individuals with serious and complex
services, OR
medical conditions
The individual has a serious and complex
medical condition AND
The condition significantly impairs the ability
to perform one or more activities of daily living
(ADLs) (Go to Box 7 to describe the
impairment in ability to perform ADLs).
4. Individuals with a physical disability
The individual has a physical disability AND
The condition significantly impairs the ability to
perform one or more activities of daily living
(ADLs) (Go to Box 7 to describe the
impairment in ability to perform ADLs).
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical