Status Of Nursing Facility Care Form - Colorado Department Of Health Care Policy And Financing
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1COLORADO DEPARTMENT OF HEALTH CARE POLICY AND FINANCING
Original Copy
______
STATUS OF NURSING FACILITY CARE
Corrected Copy
______
I . CLIENT INFORMATION:
County Transfer Copy
______
Client:
Change Pt. Pmt. Copy
______
Final Discharge Copy
______
Last Name
First Name
MI
County
State ID
_______________________/_________
_____________
__________
________________________
__________________________
CBMS
H.H. No.
Cat
Client D.O.B.
Gender
Date of Medicaid Application
Patient Level-of-care
_______________________
__________________________
______________________________
____________________________
Client’s Own S.S. Number
S. S. Claim Number/Suffix
R. R. Claim Number
V. A. Claim Number
Name and Address of Responsible Party
Relationship
______________
II:
Facility Information:
Provider Number:
____________________
Nursing Facility:
Phone Number:
__________________________________________________
_____________________
Address:
Medicaid Per Diem Rate $
________________________________________________________
____________
III: Financial Arrangement:
A.
Patient Income
B. Monthly Income Adjustments
C. Patient
Payment Calculations
Soc. Sec.
___________
Personal Needs
__________
Total Income
$ ___________
SSI
___________
Trustee/Maintenance Fees
__________
Total Deductions
$ ___________
RR
___________
Income Taxes
__________
LTC Insurance payment $ ___________
VA
___________
Community Spouses Allowance
__________
Patient Payment
$ __________
Interest
___________
Dependent Care Allowance
__________
* If patient payment is -0-, give reasons:
Other
___________
Home Maintenance Allowance
__________
_____________________________
Total Income
___________
Other * (See Note Below)
__________
Admit Month
$ ___________
Total Deductions
__________
First Full Month
$ ___________
nd
2
Month
$_ __________
D.
Change in Patient Payment
Check
* Note: Medicare Part B Premium
st
nd
If Client has
deductible for the 1
and 2
month, Medicare
Month _______
$ __________
Health Insurance
Part D continuous, if applicable.
Month _______
$ __________
IV.
We Request Medical Authorization for Medicaid Nursing Facility Care for the Above Patient:
Original Admission Date to Nursing Facility _________
or original date hospitalized ___________________________
Admitted to Medicaid _____________________ 20 ________
Discharged
_____________________ 20 ________
From:
Home
Medicare
To: home
Address ______________________________
Hospital
Hosp Name __________________
# Days in hospital ___________ # Days in NF ___________
Readmitted to Medicaid ___________________ 20 ____________
Medicare
NF
LOA
YTD Total ___________
From: Home
Medicare
NF
LOA
YTD Tot ______
Other
Specify _______________________________
Hospital
Name ____________________________________
Died ______________________________________________
Other
Specify
____________________________________
Place of Death ______________________________________
Admitted to Medicare _____________________ 20 ____________
From ________________________________ No. of Days _____
___________________________________________________
Signature of Authorized NF Representative
V.
County Transfer: (
This section is always completed by a county department staff
)
Date transferred out ____________________________ 20_____ From ___________________________________________________
County
Date transferred in
___________________________ 20 ____
To
___________________________________________________
County
VI. County Transfer: (
This section is always completed by a county department staff
)
Approved:
_____________________________________
Comments:
Discontinued:
______________________________________
__________________________________________________
Denied:
______________________________________
__________________________________________________
Effective Date: _____________________________ 20 ______
__________________________________________________
______________________________________________________
__________________________
_________________
County Technician
Phone
Date
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