Form 90-L PDF Details

Navigating the complexities of medical eligibility for various programs and services is an essential process for individuals requiring specialized care. The 90 L form, known formally as the Request for Medical Eligibility Determination, serves as a comprehensive tool designed to gather crucial information about an individual's health condition, care requirements, and personal details. It starts by collecting recipient information, including the individual's name, Social Security and Medicaid numbers, address, and contact details of a responsible party or curator. The form further delves into the recipient's living arrangements, past facility care, and home/community-based services considered or utilized, aiming to paint a full picture of the applicant's current care situation. The attending physician's input on the level of care needed—whether in an intermediate care facility for individuals with intellectual disabilities (ICF/ID), requiring skilled care, or if home/community-based services are adequate—plays a pivotal role in the decision process. Additionally, detailed medical information like diagnosis, medication, recent hospitalizations, mental status, communication abilities, and daily living activities is required, emphasizing the form's role in ensuring a holistic evaluation of the recipient's medical eligibility. This thorough approach enables a tailored assessment, guiding the allocation of appropriate care and services to those in need.

QuestionAnswer
Form NameForm 90-L
Form Length2 pages
Fillable?Yes
Fillable fields152
Avg. time to fill out30 min 58 sec
Other nameslouisiana 90l form printable, 90l louisiana, form 90l, louisiana 90 l

Form Preview Example

REQUEST FOR MEDICAL ELIGIBILITY DETERMINATION

I. RECIPIENT INFORMATION

A. Recipient’s Name:

 

 

 

 

 

SS #:

 

Medicaid #:

 

 

 

 

 

 

 

 

 

 

 

B. Address (City, State, Zip Code, Parish):

 

 

 

 

C. Responsible Party/Curator:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address (City, State, Zip Code, Parish):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone #:

 

 

Sex:

 

M

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medicare #:

 

 

Date of Birth:

 

Relationship:

 

Telephone #:

 

 

 

 

 

 

 

 

 

D. What are/were the living arrangements:

Own home

Relative’s home

Other:_______________________

 

 

 

 

 

 

 

E. What previous facility care has this person received?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Facility:

 

 

Date:

 

 

 

 

Facility:

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

Facility:

 

 

Date:

 

 

 

 

Facility:

 

 

Date:

 

 

 

 

 

 

 

F. What Home/Community-based services have been used/considered:

 

 

 

 

 

NOW

CC

Supports

ROW

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

G. Applicant/Responsible Party Signature:______________________________________Date:______________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

II. LEVEL OF CARE

 

 

 

 

 

 

 

 

 

 

The attending physician must designate the required level of care:

 

 

 

 

A.

ICF/ID - Requires active treatment of developmental disability under supervision of a qualified intellectual / developmental

 

disability professional.

 

 

 

 

 

 

 

 

 

 

 

B.

Skilled Care (maximum care required) – Indicate special level, if needed: TDC

ID

NRTP ( Complex; Rehab)

Includes professional nursing care and assessment on a daily basis due to a serious condition which is unstable or a rehabilitative therapeutic regime requiring professional staff.

C. Are Home/Community Based Services adequate to meet the needs of this patient?

D. COMMENTS:

Yes

No

III.MEDICAL INFORMATION

A.Diagnosis:______________________________________________________________________________________________

__________________________________________________________________________________________________________

B.Medications:(Specify dosage, frequency, and route) ALLERGIES________________________________________________

1. __________________________________ 5. ___________________________________ 9. ______________________________

2.__________________________________ 6. ___________________________________ 10. _____________________________

3.__________________________________ 7. ___________________________________ 11. _____________________________

4.__________________________________ 8. ___________________________________ 12. _____________________________

Page 1 of 2

OCDD Form 90-L

 

Rev. 03/26/18

Recipient’s Name:

C. Recent Hospitalizations:

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

D. Mental Status/Behavior: check Yes or No. If Yes, indicate frequency: 1 = seldom; 2 = frequent; 3 = always

Yes

(1, 2, 3 )

No

1.

Oriented

 

Yes

(1, 2, 3 )

No

4.

Comatose

Yes

(1, 2, 3 )

No

7.

Hostile

Yes (1, 2,

3 )

No

2.

Forgetful

 

Yes (1, 2, 3 )

No

5.

Confused

Yes

(1, 2, 3 )

No

8.

Combative

Yes

(1, 2,

3 )

No

3.

Depressed

 

Yes

(1, 2, 3 )

No

6.

Wanders

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E. Communications:

 

Verbal

Non-verbal

 

 

 

 

 

 

 

 

 

F. Activities of Daily Living: (check appropriate box)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SELF ASSIST TOTAL

 

 

 

9. Impaired vision _________________________

 

 

1. Eating

 

 

 

 

 

 

 

 

 

 

 

 

 

Glasses

 

 

2. Bathing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. Personal

 

 

 

10. Impaired hearing_______________________

 

 

4. Ambulation

 

 

 

 

 

 

 

 

 

 

 

 

 

Hearing Aid

 

 

5. Transfer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. Bowel Incontinence

 

 

 

11. Dentures _____________________________

 

 

7. Bladder Incontinence

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. Urinary Catheter

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

G. SPECIAL CARE/PROCEDURES: (check appropriate box: when appropriate give type, frequency, size, stage and site)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. Ostomy care____________________________________

 

8. Diet/Tube Feeding

 

 

 

2. Glucose Monitoring______________________________

 

9. Dialysis

 

 

 

3. Restraints _____________________________________

 

10. Respiratory

 

 

 

4. IV’s__________________________________________

 

11. Wound Care/Decubitus

 

 

 

5. Suctioning_____________________________________

12. Tracheostomy Care

 

 

 

6. Specialized Rehab________________________________

 

13. Ventilator Dependent

 

 

 

7. MRSA/Infections

 

14. Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

H. PHYSICAL EXAMINATION: Height__________Weight________Pulse________Resp________Temp________B/P__________

 

Lab Results: HCT_________HGB__________U/A___________

Radiology

 

 

 

General_____________________________________________

Head and CNS

 

 

 

Mouth and EENT______________________________________

Chest

 

 

 

Heart and Circulation__________________________________

Abdomen

 

 

 

Genitalia____________________________________________

Extremities

 

 

 

Skin________________________________________________

Other

 

 

 

 

 

 

 

 

I. MD Signature is required. A Nurse Practitioner/Physician Assistant signature is allowed for Children’s Choice, Supports

 

Waiver, Residential Options Waiver, and New Opportunities Waiver participants. In all cases a supervising physician must be

 

identified.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physician’s Name (print):__________________________________________________________Phone:_______________________

 

Address:__________________________________________________________________________________________________

 

Nurse Practitioner/Physician Assistant Name (print):________________________________________________________________

 

Physician/Nurse Practitioner/Physician Assistant Signature:__________________________________________________________

 

Date: ______________________

 

 

 

(Signer please identify profession/credentials)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 2 of 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OCDD Form 90-L

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rev. 03/26/18

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how to form 90l conclusion process shown (portion 1)

2. Given that this part is finished, you should put in the essential specifics in A Recipients Name SS B Address, Supports ROW Other, NOW CC G ApplicantResponsible, II LEVEL OF CARE, The attending physician must, ICFID Requires active treatment, NRTP Complex Rehab, C Are HomeCommunity Based Services, D COMMENTS, III MEDICAL INFORMATION, and A Diagnosis B MedicationsSpecify allowing you to proceed to the third part.

Stage no. 2 of filling in how to form 90l

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Step number 3 for submitting how to form 90l

4. The next part needs your input in the subsequent parts: Recipients Name, C Recent Hospitalizations D, Yes No Oriented Yes No, Yes No Comatose Yes No, Yes No Hostile Yes No, E Communications Verbal Nonverbal, Eating Bathing Personal, Impaired vision, Glasses, Impaired hearing, Hearing Aid, Dentures, and G SPECIAL CAREPROCEDURES check. Be sure to fill in all required info to go forward.

how to form 90l writing process shown (stage 4)

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5. Last of all, this last subsection is what you'll have to wrap up prior to finalizing the PDF. The fields at this point include the next: Ostomy care Glucose Monitoring, DietTube Feeding Dialysis, Ventilator Dependent Other, and H PHYSICAL EXAMINATION.

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