West Virginia Traumatic Brain Injury (Tbi) Waiver Medical Necessity Evaluation Request (Mner) Form

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WEST VIRGINIA TRAUMATIC BRAIN INJURY (TBI) WAIVER
MEDICAL NECESSITY EVALUATION REQUEST (MNER) FORM
Please check one: _____ Initial _____Reevaluation
Demographic Information
First Name, MI, Last
Social Security Number
Name
Currently Inpatient:
If yes, Name of Facility:__________________________ Contact Person:_______________________
___Yes ___No
Address:__________________________________City:_________________State:____ Zip:________
Phone #:________________________________ Fax #:_____________________________________
Type of facility: _____Nursing Facility _____Rehabilitation Facility _____Inpatient Hospital
Home Mailing Address:
County of Residence:______________________________
Address_________________________________City______________State_________Zip:_________
Home Phone Number :
Gender (circle one)
Email (if
Male or Female
applicable)
Date of Birth
Medicaid #
(MUST be 3 or older)
(if applicable)
Medicare #
Other health insurance
(if applicable)
(if applicable)
Legal Representative Information
___Check here if
Relation to applicant (check one): ___ Legal guardian
Family Member? ______Yes ______No
applicant/program
___ Medical Power of Attorney ___ Durable Power of Attorney ___ Healthcare Surrogate
participant is his/her
___Other, Please Explain:____________________________________________________________
own representative
First Name, MI, Last
Phone
Name:
Number:
Mailing Address:
Applicant/current TBIW Participant /Legal Representative Signature
I certify that the above information is accurate and complete to the best of my knowledge. I understand the information
provided in this document will be treated confidentially.
____________________________________________________________
_____________________________
Signature of Applicant/Recipient or Legal Representative
Date
Case Management Agency (Reevaluations Only)
Agency Name:_____________________________________________ Case Manager:________________________________
Mailing Address: _______________________________________ City:_______________________ State:____ Zip:__________
Phone #:_______________________________Fax #___________________________
Referring Physician/Practitioner Information (Please Print)
Physician/Practitioner
Name
Phone #
Fax #
Mailing Address
Client’s Diagnoses:
(Please list all and
____________________________________________________________________________________
include type of TBI)
Include current ICD-
____________________________________________________________________________________
Code(s)
Functional deficits
(Please check if assistance is needed):
____ Eating ____ Dressing ____ Orientation ____ Wheeling
directly attributable
____ Communication ____ Bathing ____Cont./Bladder ____ Transferring ____ Vision
____ Grooming ____ Cont./Bowel ____ Walking ____ Hearing
to TBI:
I attest that the individual’s condition meets the entry level definition of TBI: A non-degenerative, non-congenital insult to the
brain caused by an external physical force resulting in total or partial functional disability and/or psychosocial impairment or
injury of anoxia due to near drowning.
_________________________________________________________________
______________________________
Signature of Physician/Practitioner (MD, DO, PA-C, APRN or Neuropsychologist)
Date (Valid for 60 days)
Form Submission
Mail or fax completed form to
APS Healthcare, Inc.-WV 100 Capitol Street, Suite 600, Charleston, WV 25301
Fax: 866-607-9903 | Phone: 866-385-8920
DO NOT WRITE BELOW THIS LINE
Received by the Administrative Service Organization:
_____________________________________________________________________________________________________
Signature of ASO Representative Receiving Form
Date
WV-TBI Waiver Medical Necessity Evaluation Request Form 10/2015

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