Form 1147 – Fill Out and Use This PDF

1. PLEASE PRINT OR TYPE

Initial Request

Annual Review

Other review

2. PATIENT NAME (Last, First, M.I.)

3. BIRTHDATE

4. SEX

5. MEDICARE

6.

MEDICAID ELIGIBLE?

Month/Day/Year

Part A

Yes

No

Yes ID # _______________________

Part B

Yes

No

No Date Applied _________________

ID#:___________________

7. PRESENT ADDRESS: Present Address is

Home

Hospital

NF

Care Home

EARCH

8. Medicaid Provider Number:

CCFFH

Other: _____________________

(If applicable)

9. ATTENDING PHYSICIAN/PRIMARY CARE PROVIDER (PCP) (Last Name, First Name, Middle Initial)

_______________________________________________________________________

Phone : (

)__________________ Fax: ( )_____________________________

10. RETURN FORM TO (SERVICE COORDINATOR/CONTACT PERSON): _______________________________________________________________

MANAGED CARE PLAN NAME (IF APPLICABLE): ________________________________________________________________________________

[ ] VIA FAX (Print Fax Number Below)

Phone (

)_________________

Fax (

) _______________________ Email (

) _________________________________________________

11.

REFERRAL INFORMATION (Completed by Referring

12.

ASSESSMENT INFORMATION (Completed by RN, Physician, PCP)

Party)

A. SOURCE(S) OF INFORMATION

A. ASSESSMENT DATE

/

/

Client

Records

Other

B.

ASSESSOR’S NAME

B. RESPONSIBLE PERSON

Name

Name

Last

First

MI

Last

First

Title

_____________________________________________________

MI

Relationship

Signature _________________________________________________

Hard copy

PHONE (

)

FAX (

)

signature on file.

C. Language

English

Other

PHONE: (

)

FAX: (

) ______________

EMAIL: (

) ____________________________________________

13. REQUESTING LEVEL OF CARE

CHECK ONE BOX:

LEVEL OF CARE BEGIN and END DATES: ___________ TO __________

[

]

Nursing Facility (ICF)

LENGTH OF APPROVAL REQUESTED (CHECK ONE BOX):

[

]

Nursing Facility (SNF)

[

]

Nursing Facility (HOSPICE)

[

]

1 month

[

]

3 months

[

]

Nursing Facility

(Subacute I)

[

]

6 months

[

]

1 year

[

]

Nursing Facility (Subacute II)

[

]

Acute Waitlist (ICF)

[

] Other: ____________________

[

]

Acute Waitlist (SNF)

[

]

Acute Waitlist

(Subacute)

14. MEDICAL NECESSITY / LEVEL OF CARE DETERMINATION – DO NOT COMPLETE

LEVEL OF CARE APPROVAL:

LEVEL OF CARE BEGIN AND END DATES: ___________ TO __________

[

] Nursing Facility (ICF)

LENGTH OF APPROVAL (CHECK ONE BOX):

[

]

Nursing Facility (SNF)

[

]

Nursing Facility (HOSPICE)

[

]

1 month

[

]

3 months

[

]

Nursing Facility

(Subacute I)

[

]

Nursing Facility (Subacute II)

[

]

6 months

[

]

1 year

[

]

Acute Waitlist (ICF)

[

]

Acute Waitlist (SNF)

[

] Other: _____________________

[

]

Acute Waitlist (Subacute)

Comments:

DEFERRED:

[

]

Current 1147 Version Needed

[

] Missing Information

[

] DOES NOT MEET LEVEL OF CARE REQUESTED

[

] INCOMPLETE INFORMATION TO DETERMINE LEVEL OF CARE

DHS REVIEWER’S / DESIGNEE’S SIGNATURE:

DATE:

DHS 1147 (Rev. 01/09)

DO NOT MODIFY FORM

Page 1 of 3

Legible photocopies and facsimiles will be acknowledged as original

STATE OF HAWAII

STATE OF HAWAII

HEALTH SERVICES ADVISORY GROUP, INC.

Department of Human Services

1440 Kapiolani Blvd., Suite 1110 Honolulu, HI 96814

Level of Care (LOC) Evaluation

Med-QUEST Division

Phone: (808) 440-6000 Fax: (808) 440-6009

APPLICANT/CLIENT BACKGROUND INFORMATION (Please Type or Print)

1. NAME (Last, First, Middle Initial)

2. BIRTHDATE

DHS 1147 (Rev. 01/09)

DO NOT MODIFY FORM

Page 2 of 3

Legible photocopies and facsimiles will be acknowledged as original

STATE OF HAWAII

STATE OF HAWAII

HEALTH SERVICES ADVISORY GROUP, INC.

Department of Human Services

1440 Kapiolani Blvd., Suite 1110 Honolulu, HI 96814

Level of Care (LOC) Evaluation

Med-QUEST Division

Phone: (808) 440-6000

Fax: (808) 440-6009

APPLICANT/CLIENT BACKGROUND INFORMATION (Please Type or Print)

1. NAME (PRINT Last, First, Middle Initial)

2.

BIRTHDATE

XVII. SKILLED PROCEDURES: D = Daily Indicate number of times per day

L = Less than once per day

N = Not applicable / Never

D

L

N

#

√

√

PROFESSIONAL NURSING ASSESSMENT/CARE RELATED TO MANAGEMENT OF:

___

[

]

[

]

Tracheostomy care/suctioning in ventilator dependent person

___

[

]

[

]

Tracheostomy care/suctioning in non-ventilator dependent person

___

[

]

[

]

Nasopharngeal suctioning in persons with no tracheostomy

___

[

]

[

]

Total Parenteral Nutrition (TPN) {Specify number of hours per day}:

___

[

]

[

]

Maintenance of peripheral/central IV lines

___

[

]

[

]

IV Therapy (Specify agent & frequency):

________

___

[

]

[

]

Decubitus ulcers (Stage III and above)

___

[

]

[

]

Decubitus ulcers (less than Stage III); wound care {Specify nature of ulcer/wound and care prescribed}

________________________________________________________________________________________________________

___

[

]

[

]

Wound care (Specify nature of wound and care prescribed)

debridement

Irrigation

packing

wound vac.

_________________

___

[

]

[

]

Instillation of medications via indwelling urinary catheters (Specify agent):

___

[

]

[

]

Intermittent urinary catheterization

___

[

]

[

]

IM/SQ Medications (Specify agent.) :

___

[

]

[

]

Difficulty with administration of oral medications (Explain):

___

[

]

[

]

Swallowing difficulties and/or choking

___

[

]

[

]

Stable Gastrostomy/Nasogastric/Jejunostomy tube feedings; Enteral Pump?

Yes

No

___

[

]

[

]

Gastrostomy/Nasogastric/Jejunostomy tube feedings in persons at risk for aspiration (Specify reason person at risk for aspiration)

_________________________________________________________________________________________________________

___

[

]

[

]

Initial phase of Oxygen therapy

___

[

]

[

]

Nebulizer treatment

___

[

]

[

]

Complicating problems of patients on [

] renal dialysis, [

] chemotherapy, [

] radiation therapy, [ ] with orthopedic traction

(Check problem(s) and describe) :

___

[

]

[

]

Behavioral problems related to neurological impairment (Describe):

___

[

]

[

]

Other (Specify condition and describe nursing intervention): ________________________________________________________

Yes

No

Therapeutic Diet

(Describe):

Yes

No

Restorative Therapy (check therapy and submit/attach evaluation and treatment plan):

PT

OT

Speech

Yes

No

The patient is able to participate in therapy a minimum of 45 minutes per session 5 days a week.

XVIII. SOCIAL SITUATION:

A. Person can return home Yes

No

N/A

Community setting can be considered as an alternative to facility?

Yes

No N/A

B. If person has a home; caregiving support system is willing to provide/continue care.

Yes

No

Caregiver requires assistance?

Yes

No

Assistance required by Caregiver:

C. Caregiver name:

Name:

Relationship:

Last

First

MI

Address:

Phone: (

)

Fax (

)

XIX. COMMENTS ON NURSING REQUIREMENTS OR SOCIAL SITUATION:

I HAVE REVIEWED AND AGREE WITH THE LEVEL OF CARE ASSESSMENT.

PHYSICIAN’S SIGNATURE/PCP: __________________________________________

Hard copy signature on file. This plan of care has been discussed with the MD/PCP.

DATE:

/

/

Physician’s/PCP Name (PRINT): ___________________________________________

DHS 1147 (Rev. 01/09)

DO NOT MODIFY FORM

Page 3 of 3

Legible photocopies and facsimiles will be acknowledged as original