Medically Frail Attestation & Referral Form (Page 3 of 4) in pdf

Medically Frail Attestation & Referral Form Page 3

5. Individuals with an intellectual or

The individual has an intellectual or

developmental disability

developmental disability as defined in IAC 441-

24.1. This definition means a severe, chronic

disability that:

Is attributable to a mental or physical

impairment or combination of mental and

physical impairments;

Is manifested before the age of 22;

Is likely to continue indefinitely;

Results in substantial functional limitations

in three or more of the following areas of

major life activity: self-care, receptive and

expressive language, learning, mobility,

self-direction, capacity for independent

living, and economic self-sufficiency; and

Reflects the person’s need for a

combination and sequence of special,

interdisciplinary, or generic services,

individualized supports, or other forms of

assistance that are of lifelong or extended

duration and are individually planned and

coordinated.

The condition significantly impairs the ability to

perform one or more activities of daily living

(ADLs)* (see below for details on ADLs).

(Go to Box 7 to describe the impairment in

ability to perform ADLs).

6. Individuals with a disability determination

The individual has a current disability

designation by the Social Security

Administration.

7. Use the box below to describe the activities of daily living (ADLs) the member needs assistance

with and the frequency of that need.

(Examples of ADLs may include but are not limited to bathing and showering, bowel and bladder

management, dressing, eating, feeding, functional mobility, personal device care, personal

hygiene and grooming and/or toilet hygiene.)

Medically Frail Attestation & Referral Form Page 3