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MEDICAL CERTIFICATION FOR NURSING FACILITY/HOME- AND COMMUNITY-BASED SERVICES FORM

(Replaces Patient Transfer and Continuity of Care Form)

(A)

FACILITY INFORMATION

(E)

HISTORY & PHYSICAL AND LABS

Facility From _____________________________

Admission Date

Discharge Date

1. PHYSICAL EXAM (History & Physical may be attached)

Facility To

Head Ears Eyes Nose & Throat (HEENT)

_____________________________

______/______/______

(B)

DEMOGRAPHIC INFORMATION

Sex

Race

Individual's DOB

_______/_______/_______

__________

Neck

Cardiopulmonary

_______________________________________________________________________________________

Individual's Last Name

First Name

Initial

Abdomen

_______________________________________________________________________________

Individual's Address

Phone Number

Rectal

_______________________________________________________________________________

Extremities

Nearest Relative/Health Care Surrogate

Phone Number

Neurological

Other

PHYSICIAN INFORMATION

Name

Free from communicable diseases

Yes

Will you care for individual in NF?

Yes

2. LABORATORY FINDINGS (Reports may be attached)

If no, referred to __________________________________________________________________

TB Test

Yes

Date _______/_______/_______

Principal Diagnosis ______________________________________________________________

Results

Secondary Diagnosis ____________________________________________________________

Chest X-Ray

Yes

Date _______/_______/_______

Results

Discharge Diagnosis _____________________________________________________________

(Problem List may be attached)

(F)

IMMUNIZATIONS GIVEN

Surgery Performed & Date

_____________________________________/_______/_________

Allergy/Drug Sensitivity___________________________________________________________

Pneumococcal Vaccine

Date _______/_______/_______

MEDICATION AND TREATMENT ORDERS (copies may be attached)

Influenza Vaccine

Date _______/_______/_______

Tetanus and Diphtheria Vaccine

Date _______/_______/_______

Herpes Zoster Vaccine

Date _______/_______/_______

(G)

PHYSICAL THERAPY (Attach Orders)

New Referral

Continuation of Therapy

FREQUENCY OF THERAPY

(Complete for admission to NF only)

1. Is dementia the primary diagnosis?

Yes

INSTRUCTIONS

2. Is there an indication of, or diagnosis of mental retardation (MR),

or has the individual received MR services within the last 2 years?

Yes

Stretching

Coordinating Activities

Progress bed to wheelchair

3. Is there an indication of, or diagnosis of serious mental illness (MI), such as

Passive Range

Non-weight bearing

Recovery to full function

(check all that apply)

of Motion (ROM)

Partial weight bearing

Wheelchair independent

Schizophrenia

Panic or severe anxiety disorder

Active assistive

Full weight bearing

Complete ambulation

Mood disorder

Personality disorder

Active

Somatoform disorder

Other psychotic or mental disorder

Progressive resistive

Sensation Impaired:

Yes

Paranoia

leading to chronic disability

PRECAUTIONS

Restrict Activity:

Yes

4. Has the individual received MI services within the past two years?

Yes

Cardiac

5. Is the individual a danger to self or others? (please attach explanation)

Yes

Other

6. Is the individual on any medication for the treatment of a serious

Yes

ADDITIONAL THERAPIES (Attach Orders)

mental illness or psychiatric diagnosis?

7. If yes, is the MI or psychiatric diagnosis controlled with medication?

Yes

Occupational Therapy

Respiratory Therapy

8. Is the individual being admitted from a hospital after receiving acute

Yes

Speech Therapy

Other

inpatient care?

(H) TREATMENT AND EQUIPMENT NEEDS (Attach Orders)

9. Does the individual require nursing facility services for the condition

Yes

for which he/she received care in the hospital?

Catheter Care

Diabetic Care

10.Has the physician certified the individual is likely to require less than

Yes

Changing Feeding Tube

Monitor Blood Sugar/Frequency

30 days of nursing facility services?

Dressing Changes

Administer Insulin

Ostomy Care

Tube Feeding

Wound Care

Oxygen

(Select from below)

(D)

ADDITIONAL ORDERS (Orders may be attached)

Suctioning

PRN

Trach Care

Continuous @L/min

Instructions

(I)

SPECIAL DIET ORDERS (Orders may be attached)

(J)

TYPE OF CARE RECOMMENDED (MUST BE COMPLETED AND SIGNED)

Check one

Rehab Potential (check one)

Good

Fair

Poor

Skilled Nursing Extended Care Facility (ECF), Duration ______________

Intermediate Care: Duration ____________________

Admission Date to Nursing Facility _______/_______/_______

I certify that this individual requires ECF Nursing Facility Care for the condition for which he/she received care during hospitalization.

I certify that this individual is in need of Medicaid Waiver Services in lieu of Institutional placement.

Print Physician's Name

Effective Date of Medical Condition_______/______/_______

Address

Phone Number

Fax

FOR ONLINE APPLICANT USE ONLY

Email Contact Address

IF APPLYING FOR MEDICAID, PLEASE INCLUDE DCF

________________________________________________________________________________/_______/________

ACCESS CONFIRMATION NUMBER BELOW:

Physician's Signature and Date Required

AHCA MEDSERV-3008 form, May 2009--(Replaces Patient Transfer and Continuity of Care Form 3008 July 2006 - CF Med 3008)

Ahca Medserv-3008 Form - Medical Certification For Nursing Facility/home- And Community-Based Services Form

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