Ahca-Med Serv Form 049 - Aids Supplemental Payment Authorization Form printable pdf download

AIDS SUPPLEMENTAL PAYMENT AUTHORIZATION FORM

FACILITY INFORMATION

Nursing Facility Name ________________________________

Date of Request _________________

Medicaid Provider Number ______________________

Contact Person: ________________________________________ Phone Number (

) __________________

_________________________________________________________________________________________________

(Street Address)

(City)

(State)

(Zip Code)

PATIENT INFORMATION

Medicaid Recipient’s Name_________________________________________

Date of Birth ________________

Recipient’s Medicaid Number_________________

Date of Admission ____________

MEDICAL EVALUATION

CD4 Count ___________

___________ %

Viral Load ____________ as of ________________

(Absolute)

(Percentage)

(Date)

Opportunistic Infections (history or presence of, related to the HIV infection)

___ Candidiasis of bronchi, trachea, lungs, or esophagus

___ Cervical Cancer, Invasive

___ Coccidioidomycosis

___ Cryptococcosis

___ Cryptosporidiosis, chronic intestinal (>1 month's

___ Cytomegalovirus disease (other than liver, spleen,

duration)

or nodes), onset at age >1 month

___ Cytomegalovirus retinitis (with loss of vision)

___ Encephalopathy, HIV related

___ Herpes simplex: chronic ulcers (>1 month's duration)

___ Bronchitis, pneumonitis, or esophagitis (onset at

___ Histoplasmosis, disseminated or extrapulmonary

age >1 month)

___ Isosporiasis, chronic intestinal (>1 month's duration)

___ Kaposi sarcoma

___ Lymphoid interstitial pneumonia

___ Lymphoma (malignant)

___ Pneumonia, recurrent

___ Mycobacterial infections

___ Pneumocystis jirovecii pneumonia

___ Progressive multifocal leukoencephalopathy

___ Toxoplasmosis of brain

___ Salmonella septicemia, recurrent

___ Wasting syndrome attributed to HIV

Describe Current Treatment

_________________________________________________________________________________________________

List any restrictions with activities of daily living or other physical/mental limitations

_________________________________________________________________________________________________

AHCA-Med Serv Form 049, July 2008

Page 1 of 2

Ahca-Med Serv Form 049 - Aids Supplemental Payment Authorization Form

Related Articles

Related forms

Related Categories