Form Teb-Adbltchome-072413 - Accelerated Death Benefit For Long Term Care Claim Form Page 2
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1
2
3
4Assessment Form
To be completed by Case Manager, Social Security Worker, Registered Nurse or Physician
1. Patient Name
2. Date of Birth
3. Diagnosis
1.
2.
3.
4.
5.
6.
4. Was Patient Hospitalized?
Yes No
5. Was Patient in a Nursing Home Facility?
Yes No
From
To
From
To
6. Period Authorized
7. Medicare Coverage
Yes No
From
To
8. The above listed patient requires care to perform the following Activities of Daily Living or Instrumental Activities of Daily Living.
I = Independent
S = Stand-by Assistance at Arm’s Length
O = Needs Hands-On to Perform
ADL
I
S
O
IADL
I
O
Bathing
Medicine Admin
Dressing
Personal Finances
Toileting
Prepare/Cook Meals
Continence
Use Telephone
Mobility
Housework
Transfers
Laundry
Feeding/Eating
9. Cognitive Impairment:
Yes No
(If “Yes”, attached Clinical Test/Documentation)
10. I hereby certify that the above listed patient will be chronically ill for a period of 90 days or more:
Yes No
11. Patient Requires:
Home Health Care
Adult Day Care
Hospice Program
Respite Care
Assisted Living Facility
Other __________________________________________
12. Recommended Services: Nurse Therapist Homemaker Companion Other ___________________________________
13. Total Number of Days Per Week
14. Number of Hours Per Day 15. Where Is Care Being Provided? Home
Apartment
Retirement Community
Facility
Other _________________
16. Name of Provider
17. Tax ID/Social Security No.
18. Phone No.
19. Street Address
20. City
21. State
22. Zip Code
23. Type of License:
Heath Care Agency
Adult Day Care Agency
Hospice Program
Other
24. Print Name
25. Degree
26. Phone No.
27. Street Address
28. City
29. State
30. Zip Code
Signature
Date
Attach the following documents:
1)
Plan of Care
2)
Itemized Billing Statement
3)
Explanation of Medicare Benefit Statements (if Medicare coverage on these services)
TEB-ADBLTCHome-072413
Page 2 of 4
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