Form Fh 17 PDF Details

Navigating the complexities of Medicare and Medicaid benefits for those requiring nursing care can often present a formidable challenge, made somewhat easier by essential forms like the FH-17. Specifically designed for use within the Nevada Medicaid and Nevada Check Up First Health Services Corporation, the FH-17 Level of Care Assessment Form for Nursing Facilities serves a critical role in streamlining the process of requesting nursing facility services. By substantiating the need and level of care required, whether it be for initial placement, retro-eligibility, service level change, or addressing time limitations, this form acts as a linchpin in ensuring recipients receive the appropriate care. It meticulously collects provider information, including provider name and Medicaid number, alongside recipient details such as name, identification number, and medical history, thereby facilitating informed decisions regarding the necessary care level. Additionally, it addresses potential barriers to self-medication, outlines special needs ranging from basic medical interventions like glucose monitoring to more complex care requirements such as ventilator dependency, and evaluates the recipient's ability to perform daily activities. This comprehensive assessment not only aids in the allocation of correct service levels — from standard care to pediatric specialty and ventilator-dependent care — but also ensures that both acute and long-term needs are meticulously planned for, underscoring the form's integral place within the process of securing nursing facility care for individuals under the Nevada Medicaid system.

QuestionAnswer
Form NameForm Fh 17
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesNevada, IADL, G-tube, PICC

Form Preview Example

Nevada Medicaid and Nevada Check Up

First Health Services Corporation

Level of Care Assessment Form for Nursing Facilities

To Transmit Request: Phone: (800) 525-2395 Fax: (866) 480-9903 Mail: 4300 Cox Road, Glen Allen, VA 23060

DATE OF REQUEST: ______ /______ /________

REASON FOR SCREENING:

Initial Placement

Retro-Eligibility Service Level Change

Time Limitation

SERVICE LEVEL: Standard

Pediatric Specialty Care I

Pediatric Specialty Care II

Ventilator Dependent

 

 

 

 

 

 

PROVIDER INFORMATION

 

 

 

 

 

Provider Name: _________________________________________

Provider Medicaid Number: _______________________

Address: _________________________________________ City: ________________ State: _______ Zip Code: __________

Person Completing This Form: ___________________________________ Professional Title: __________________________

Contact Phone: ______________________ Contact Fax: ______________________ Contact Pager: ___________________

RECIPIENT INFORMATION

Last Name: ______________________ First Name: _____________________ MI: ___ Recipient ID Number: ______________

Date of Birth: _____________ SSN: __________________ Screening Location:

Acute

Nursing Facility

Home

Other

Name of Admitting Nursing Facility: _____________________________________________ Admit Date: __________________

MEDICAL HISTORY

Diagnosis / ICD-9 Code Related to Placement (list up to three): 1.Diagnosis:______________________ICD-9 Code:__________

2.Diagnosis:_____________________ICD-9 Code:__________ 3.Diagnosis:_____________________ICD-9 Code:__________

Medications: ___________________________________________________________________________________________

1

2

Can recipient safely self-administer medications?

Yes

No - List barriers: _____________________________________

Special Needs: Central Line Feeding Tube (G-tube, J-tube, NG tube) Glucose Monitoring

Insulin Coverage (sliding scale with variable coverage)

 

IV

 

 

O2

 

Ostomy

 

Pediatric Specialty Care

 

PICC

Saline-Lock

 

Secured (Alzheimer) Unit

 

 

Specialty Bed

 

 

Suctioning

 

Trach

 

 

Ventilator Dependent

 

Wound Care

 

 

 

 

 

 

 

 

 

 

 

 

DME: _______________________________

 

 

Other: _____________________________________________________

For checked items above, list the frequency/duration of treatment, the stage/grade/size/location of wounds and/or any other specific treatments: ________________________________________________________________________________________________

3

Activities of Daily Living (ADL): Check all boxes that pertain and add comments as necessary.

 

Activity

 

Self

 

Super-

 

Assis-

 

 

Depen-

 

 

 

 

 

 

Comments

 

 

 

 

 

 

Care

 

vision

 

tance

 

 

dent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bed Mobility

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Transfer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Locomotion

 

 

 

 

 

 

 

 

 

 

No Devices

 

 

Wheelchair

 

 

Walker

 

Cane

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dressing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Eating/Feeding

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hygiene

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bathing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bladder Function

 

 

 

 

 

 

 

 

 

 

Continent

 

 

 

Incontinent

 

 

Catheter

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bowel Function

 

 

 

 

 

 

 

 

 

 

Continent

 

 

Incontinent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4Recipient’s Need for Supervision: Behavior Problem

 

Resists Care

 

Socially Inappropriate

 

 

Wandering

 

Physically Abusive

Safety Risk

Verbally Abusive

5Instrumental Activities of Daily Living (IADL)

Meal Preparation

Homemaking Services - related to personal care

Comments: ________________________________________________________________________________

FH-17

Page 1 of 1

12/28/04

 

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