Bhsf Form 142 PDF Details

BHSF Form 142 is a financial statement used to report the financial position of a business. The form includes information on a company's assets, liabilities, and equity. The form can be used to assess the overall financial health of a business and make decisions about investing in the company. The form must be filed with the Securities and Exchange Commission (SEC) every year. The purpose of this blog post is to provide an overview of BHSF Form 142 and discuss some of the key components of the form. We will also provide examples of how to read and interpret BHSF Form 142. Finally, we will offer tips for preparing and filing this form with the SEC. Stay tuned!

QuestionAnswer
Form NameBhsf Form 142
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameslousiana 142 form for nursing home, what is a 142 form used for nursing home placement, louisiana form 142 for nursing home placement, 142 form

Form Preview Example

BHSF FORM 142 REV. 07/12

PRIOR ISSUE OBSOLETE

Louisiana Department of Health and Hospitals

Medicaid Program

Notice of Medical Certification

SSN:

Date of Birth:

 

Medicaid No:

To:

 

 

 

 

 

 

 

 

 

 

Home Address:

 

 

 

 

 

 

 

 

 

Facility/Provider/Support Coordinator Name:

 

 

 

 

 

Vendor No:

 

Facility Address:

 

 

 

 

 

Parish:

 

 

 

 

 

 

 

 

 

 

 

 

 

Nursing Facility or Intermediate Care Facility

•Eligibility must be approved prior to admission to Nursing Facility. Prior approval is valid for 30 days for Nursing Facility Admission. If admitted within 30 days, decision is valid until discharged. If not admitted within 30 days of decision, a new decision is needed.

•This decision relates to medical eligibility only and is separate from a decision on financial eligibility for Medicaid.

I.

A. Approved for Medicaid/Private medical eligibility services effective

 

.

 

 

 

 

 

 

 

 

 

 

 

 

Level II decision pending.

 

 

Level of Care:

 

 

 

 

B. Approved for Medicaid medical eligibility services for a temporary period effective

 

 

 

 

through

 

.

Level of Care:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please check:

 

 

 

 

 

 

 

 

 

MD/Physician involvement

 

 

TDC

 

 

 

Treatment/Conditions

 

 

NRTP

 

 

 

Skilled Therapies

 

 

Other:______________________

 

 

 

Hospital Exemption

 

 

 

 

 

 

 

 

C. Not Approved/Denied – Does not meet Medicaid medical eligibility requirement.

D. ICF/DD decision pending-additional information needed:

Agency Representative

 

Date:

 

 

 

 

OCDD/OAAS Office Address

II. If item F, G, or H is marked, disregard Section I decision.

E.

Level II decision is not required.

 

 

 

 

 

 

 

 

F.

Approved for admission by Level II Authority effective

 

 

 

 

 

 

 

 

.

G.

Approved for admission by Level II Authority for a temporary period effective

 

through

.

H.

Not Approved – Admission Denied by Level II Authority.

 

 

 

 

 

 

 

 

Agency Representative

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OCDD/OBH Office Address

 

 

 

 

 

 

 

 

 

III. WAIVER/PACE

 

 

 

 

 

 

 

 

A.

Approved Medicaid waiver criteria for

 

 

Waiver services effective

 

.

B.

Not Approved - Does not meet Medicaid medical eligibility.

 

 

 

 

 

 

 

 

C.

Vendor Payment May Begin Date:

 

 

 

 

 

 

 

 

 

Agency Representative/Support Coordinator:

 

Date:

 

 

 

 

 

 

OAAS or OCDD Regional Office or OBH State Office:

 

 

 

 

OAAS or OCDD Regional Office or OBH State Office Address:

 

 

 

CC:

Facility/Provider

Office of Behavioral Health

Medicaid Long Term Care Unit (specify Parish):

Other (specify):

OAAS

OCDD

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Step number 1 in submitting what is a 142 form used for nursing home placement

2. The third step is usually to fill out these particular blanks: C Not ApprovedDenied Does not, D ICFDD decision pendingadditional, Date, Agency Representative, OCDDOAAS Office Address II, If item F G or H is marked, E Level II decision is not required, through, F Approved for admission by Level, G Approved for admission by Level, H Not Approved Admission Denied, Agency Representative, OCDDOBH Office Address, III WAIVERPACE, and Date.

what is a 142 form used for nursing home placement writing process described (portion 2)

3. In this particular step, take a look at Agency RepresentativeSupport, Date, OAAS or OCDD Regional Office or, OAAS or OCDD Regional Office or, FacilityProvider Medicaid Long, Office of Behavioral Health, OAAS, and OCDD. Every one of these need to be completed with greatest accuracy.

Simple tips to prepare what is a 142 form used for nursing home placement part 3

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