Fillable Medical Eligibility Review Form (Page 3 of 4) in pdf

Applicant Name ____________________________

13. Monitor Machine: For example, apnea or bradycardia

14. Formal Teaching/Training Program: Teach client or caregiver how to manage the treatment

regime or perform self care or treatment skills for recently diagnosed conditions (must be ordered

by a physician)

Table II. Rehabilitation (PT/OT/Speech Therapy services) Must be current ongoing treatment.

No. of days service

Review Item

(Please indicate the number of days per week each service is required.

is required/wk.

(0-7)

15. Extensive Training for ADLs. (restoration, not maintenance), including walking,

transferring, swallowing, eating, dressing and grooming.

16. Amputation/Prosthesis Care Training: For new amputation.

17. Communication Training: For new diagnosis affecting ability to communicate.

18. Bowel and/or Bladder Retraining Program: Not including routine toileting schedule.

Part F – Functional Assessment

Review Item

Answer

Cognitive Status (Please answer Yes or No for EACH item.)

1. Orientation to Person: Client is able to state his/her name.

2. Medication Management: Able to administer the correct medication in the correct dosage, at the

correct frequency without the assistance or supervision of another person.

3. Telephone Utilization: Able to acquire telephone numbers, place calls, and receive calls without the

assistance or supervision of another person.

4. Money Management: Can manage banking activity, bill paying, writing checks, handling cash

transactions, and making change without the assistance or supervision of another person.

5. Housekeeping: Can perform the minimum of washing dishes, making bed, dusting, and laundry,

straightening up without the assistance or supervision of another person.

6. Brief Interview for Mental Status (BIMS): Was the examiner able to administer

the complete interview? If yes, indicate the final score. If no, indicate reason.

If yes, Score: ____________

(Examination should be administered in a language in which the client is fluent.)

If No, check one of the following:

 Hearing Loss

 Applicant is rarely/never understood

 Language Barrier

 Refused

 Other

(specify) ______________________

Behavior (Please answer Yes or No for EACH item.)

Answer

7. Wanders (several times a day): Moves with no rational purpose or orientation, seemingly oblivious to

needs or safety.

8. Hallucinations or Delusions (at least weekly): Seeing or hearing nonexistent objects or people, or a

persistent false psychotic belief regarding the self, people, or objects outside of self.

9. Aggressive/abusive behavior (several times a week): Physical and verbal attacks on others including

but not limited to threatening others, hitting, shoving , scratching, punching, pushing, biting, pulling hair or

destroying property.

10. Disruptive/socially inappropriate behavior (several times a week): Interferes with activities of

others or own activities through behaviors including but not limited to making disruptive sounds, self-

abusive acts, inappropriate sexual behavior, disrobing in public, smearing/throwing food/feces, hoarding,

rummaging through other’s belongings, constantly demanding attention, urinating in inappropriate places.

11. Self-injurious behavior (several times a month): Repeated behaviors that cause injury to self, biting,

scratching, picking behaviors, putting inappropriate object into any body cavity, (including ear, mouth, or

nose), head slapping or banging.

DHMH Form #3871B

Page 3 of 4

Rev 10/11

Medical Eligibility Review Form Page 3

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