Form Map 650 - Epsdt Special Services Home Health Fax Form - Kentucky Cabinet For Health And Family Services Department For Medicaid Services Page 4
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4Commonwealth of Kentucky
Map -650
Cabinet for Health and Family Services
(Rev 11/08)
Department for Medicaid Services
EPSDT Special Services Home Health Fax Form
Explanation and Instructions
15.
County code- Enter the patient’s residence county code
16.
Phone- Enter the patient’s phone number
17.
Parent/Guardian- Enter the name of recipient’s parent or guardian
18.
Medicaid #- Enter the recipient’s Medicaid number - all 10 digits
19.
DOB- Enter the recipient’s date of birth
20.
Sex- Enter the recipients’ sex
21.
1. Diagnosis-Enter the primary diagnosis
22.
ICD-9- Enter the ICD-9 diagnosis code
23.
2. Diagnosis- Enter the secondary diagnosis
24.
ICD-9- Enter the ICD-9 diagnosis code
25.
MD Name- Enter the recipient’s ordering physician
26.
Address- Enter the physician’s address
27.
Phone #- Enter the physician’s phone number
28.
License #- Enter the physician’s license number
29.
Service Requested- Enter type of service (i.e. Private Duty Nursing, PT, OT or ST)
30.
Procedure Code- Enter the applicable procedure code requested, if known
31.
# units- Enter the number of units requested for the services
32.
Start date- Enter the first date of service for the certification/recertification period
33.
End date- Enter the last date of the certification or recertification period
34.
$ Requested- Enter the estimated dollar amount of each EPSDT service
35.
Patient name- Enter the patient name
36.
Medicaid #- Enter the 10 digit Medicaid number
37.
Does the child receive other services?
First Steps- Explain what services the child receives from First Steps
Other EPSDT- Explain what services the child receives from EPSDT (examples: PDN, therapies)
School Services- Explain what services the child receives from school through his IEP.
CCSHCN- Explain what services the child receives from the Commission for Children With Special Health
Care Needs
HCB Waiver- Explain what services the child receives from Home and Community Based Waiver including
Personal Care services
Home Health- Explain what services the child receives from regular home health services
Kidz Club- Explain what services the child receives from the Louisville based Kidz Club, if any
38.
Equipment used in the home- Explain what equipment the therapist or nurse will be using in the plan of care
39.
MD appts/ER Visits- Explain any visits that may be pertinent to continuing care for the child
40.
Brief update- Explain all the important facts that help the reviewers decide why the child needs the services
and what exactly the provider will be doing
41.
Care Coordinator- Please have the person who is in charge of the case sign this line
42.
Therapist Signature: Please have all the therapists involved for this request to sign this form.
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