Failure to complete this form accurately may result in Medicaid Recoupments.
Use: use for Medicaid Certified Nursing Home (NH) only.
Question 2: choose "No" if the person's symptoms are situational or directly related to a medical condition.
Dementia: if yes is checked, Dementia must be documented in the medical records by a physician.
| Question | Answer |
|---|---|
| Form Name | LTC-14 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 6 min |
| Edition | Rev 11 |
| Issuing agency | State of Alabama Department of Mental Health |
| Other names | LTC-14, LTC14, Form LTC-14, Level I Screening Form |
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