Doea-Cares Form 617 - Cares Request For Additional Medical Information Form - Florida Department Of Elder Affairs

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CARES Request for Additional Medical Information
Date:
___________________
To:
_______________________________________________
From: _______________________________________________
Re:
_______________________________________________
This is to notify you that the Comprehensive Assessment and Review for Long Term Care
Services, (CARES) program is in the process of determining medical eligibility for long term care
services through the issuance of a Level of Care on the above referenced individual. We are
C
C
RICK SCOTT
HARLIE
RIST
unable to release a Level of Care at this time as we are waiting for additional medical
GOVERNOR
information in order to determine medical eligibility on this case. Please expedite the additional
information so that we may provide a timely determination on this individual’s request for
assistance. In the absence of this information being provided, the Department of Children and
Families (DCF), Automated Community Connection to Economic Self Sufficiency (ACCESS)
Florida Program will not be able approve the Institutional Care Program (ICP) application. If this
is the case, the client or designated representative will be required to complete a new Request
for Financial Assistance application.
The information needed is identified below:
Medical Certification for Nursing Facility/Home and
Community Based Services Form (MCNF/HCBS) AHCA MedServ-3008
E. D
B
, P
.D.
CHARLES T. CORLEY
OUGLAS
EACH
H
SECRETARY
SECRETARY
____
Complete AHCA MedServ-3008 Form attached
____
Section B - Patient Information not included
____
Section B - Diagnoses not listed
____
Section B - Medication & Treatment Orders not listed
____
Section C - Question 1 through 10 not completed
____
Section J - Type of Care Recommended – not completed
____
Section J - Physician’s Signature – not signed
____
Section J - Effective Date – not completed
____
Section J - Signature Date – not completed
Please ensure the following checked items are also submitted:
____
History and Physical
____
Admission and Discharge Summary
____
Level II Psychiatric Evaluation
____
Level II Determination from Agency for Persons with Disabilities
____
Level II Determination Summary Report from Substance Abuse and
Mental Health
____
Other medical information:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
As soon as CARES receives the above information, we will determine medical eligibility and
forward the Level of Care determination to DCF or the appropriate agency to complete the
eligibility process. Thank you.
Signature: ___________________________Title: __________________Date: _____________
DOEA-CARES Form 617

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