Special Rehabilitation Services For Id/rc Application
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1Division of Medicaid
and
Health Financing
SPECIAL REHABILITATION SERVICES FOR ID/RC APPLICATION
Facility Name: ______________________
Form 10‐A Document #: __________________
Resident Last Name: _________________
Resident First Name: _____________________
Medicaid ID #: ______________________
Intellectual Disability Diagnosis and Code: ___________________________________________
Related Condition Diagnosis and Code: _____________________________________________
DOCUMENTATION NEEDED FOR A COMPLETE APPLICATION
An ID/RC PASRR II which indicates the resident needs specialized rehabilitation (on file at RAS)
Signed MD order for SRS Services
Date the program starts: _________________________
A copy of the comprehensive plan of care which documents the SRS program
A program that follows the Medicaid Rule R414‐502‐7 (See Utah Administrative Code)
Include the evaluation of needs with assessments, goals and steps to reach those goals
Tracking sheets for following the progress of the program
Facility staff that will be tracking and documenting the program on the MDS
The staff that will document progress monthly and revise the program when a goal is met
Documentation of outside services of professionals who specialize in providing specialized
rehabilitation services (if applicable)
FOR STATE USE ONLY
Resident qualification for SRS:
YES
NO
Effective Date: ________________________
Nurse Reviewer Signature: ________________________________
Approval Date: ______________
RESIDENT ASSESSMENT UNIT
PO Box 143111
Salt Lake City, UT 84114-3111
Phone Number: (801) 538-6155
Fax Number (801) 536-0970
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