Request For Title Xix Care Level Determination
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1
2DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Quality Assurance
Chapter 49.45(6m)(bg), Wis. Stats.
F-62256 (Rev. 06/11)
Page 1 of 2
REQUEST FOR TITLE XIX CARE LEVEL DETERMINATION
STATE AGENCY USE
Completion of this form is not mandatory; however, a
Effective Date
Nursing Care
resident’s level of care, for Medicaid reimbursement,
ORGANIC
Level Decision
cannot be evaluated and determined without the information
Date Reviewed
requested below. Collection of personal information will be
DD Care Level
Yes
Decision
used to determine the resident’s level of care and for no
other purpose
.
Reviewer
MI Care Level
No
Decision
Name - Client/Resident (Last, First, MI)
Age
Address – Client/Resident (if different from provider address)
City
County
State
Zip Code
MA Number – Client/Resident
County of Responsibility - Client/Resident
Birth Date (Month/Day/Year)
Sex
Male
Female
Name - Provider
Provider License Number
City
County
State
Zip Code
Address - Provider
I. Reason for Request (Check one.)
New Admission
Date of Admission (month/day/year):
MA Established While in Facility
Date Eligibility Established (month/day/year):
Care Level Change
Current Care Level:
Provide a list of medication(s) and treatment(s) administered including all PRN meds given in the last 30 days. You may attach a
copy of the Medication Administration Record.
OBRA Exception for Short-term Stay
Number of Days:
(Check one.)
DD or
MI
MA Waiver Application
MA Waiver Annual Recertification
II. This section is not applicable to waiver programs.
1. Place Admitted From (Home, Hospital Name, etc.)
2. Address
3. Date - Admission (if admitted from hospital)
Date - Discharge (if admitted from hospital)
4. Date - Resident First Admitted to Facility
III. Requested Level of Care (Check all that apply.)
Effective Date
ISN
ISV
SNF
ICF-1
ICF-2
SBI
DD1a
DD1b
DD2
DD3
NAT
MI
Statements that Support the Determination of this Care Level (NOTE: Nursing Facilities must submit a copy of the Level II screen for a NAT determination.)
Attach physician’s orders; list other attachments, as necessary.
DQA Staff Notes
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