Medical Evaluation
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1
2INSTRUCTIONS FOR COMPLETING
MA-51 MEDICAL EVALUATION
NOTE: THE MA-51 IS VALID AS LONG AS IT REFLECTS THE CURRENT CONDITIONS FOR THE APPLICANT
At the top of the page, mark if this is a new or updated MA-51.
Questions 1-7 are self-explanatory.
8. Physician License Number. Enter the physician license number, not the Medical Assistance number.
9. Evaluation At. Enter 1-5 to describe where evaluation took place. If 5 is used, specify where evaluation was
completed.
10. Signature. Applicant should sign if able. If unable, legal guardian or responsible party may sign.
11. Essential Vital Signs. Self-explanatory.
12. Medical Summary. Include any medical information you feel is important for determination of level of care.
Please list patient’s known allergies in this section.
13. Vacating of building. How much assistance does the patient require to vacate the building?
14. Medication Administration. Is the patient capable of being trained to self-administer medications?
15. Diagnostic Codes and Diagnoses. ICD-9-CM diagnostic codes should be put in the blocks, then written by
name in the space next to the block. List diagnoses starting with primary, then secondary, and finally tertiary.
There is room for any other pertinent diagnoses.
16. Professional and Technical Care Needs. Indicate care needed. Examples of “other” include mental health
and case management.
17. Physician Orders. Orders should meet needs indicated in box 16. Medications should have diagnoses to
support their use.
18. Prognosis. Indicate patient’s prognosis based on current medical condition.
19. Rehabilitation Potential. Indicate based on current condition. Should be consistent with box 18.
20A. Physician’s Recommendation. Physician must recommend patient’s level of care. If the box for “other” is
checked, write in level of care.
In order to provide assistance to a physician in the level of care
recommendation, the following definitional guidelines should be considered:
Nursing Facility
Personal Care Home
ICF/MR Care
ICF/ORC Care
Inpatient Psychiatric Care
Clinically Eligible (NFCE)
Requires health-related care
Provides Personal Care
Provides health-related
Provides health-related
Provides inpatient psychiatric
and
services
because
the
services such as meals,
care to MR individuals.
care to ORC individuals.
services for the diagnoses
physical condition necessitates
housekeeping, & ADL
More care than custodial
More care than custodial
and treatment of mental
care and services that can be
assistance as needed to
care but less than in a
care but less than in a
illness on a 24-hour basis, by
provided in the community with
residents who live on
NF.
NF.
or under the supervision of a
Home and Community Based
their own in a residential
physician.
Services or in a Nursing Facility.
facility.
20B. Complete only if Consumer is NFCE and will be served in a Nursing Facility. Check whether the patient
will be eventually be discharged from facility based on current prognosis. If yes, check expected length
of stay.
20C. The physician must sign and date the MA-51. A licensed physician must sign the MA-51. It may not
be signed by a “physician in training” (a Medical Doctor in Training [MT] or an Osteopathic Doctor in
Training [OT].
Questions 21 and 22 completed by the OPTIONS Unit in the Area Agency on Aging.
MA 51 - 1/04
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