The HCSP-M11Q form, also known as the Medical Request for Home Care, serves as a crucial document in the process of acquiring home care services for individuals necessitating medical assistance in their residences. Dated December 9, 2014, and intended for submission to the GSS District Office, this comprehensive form captures essential client information, including personal and contact details, alongside a detailed medical status that requires a physician's certification. The form facilitates the authorization for physicians to release medical information to the New York City HRA/Dept. of Social Services, aiming to streamline the patient's request for home care. It encompasses sections on the patient's current condition, medication regimen, hospital information, and the medical treatments received or needed, which collectively paint a clear picture of the patient's health needs. Furthermore, it probes into the patient’s ability to manage medication, the necessity for personal care and/or housekeeping assistance, the requirement for special equipment or supplies, potential referrals to health agencies, and any additional comments that could impact the care plan. This structured approach ensures that all aspects of the patient's health and home care needs are meticulously addressed, facilitating the provision of adequate care and support within the comfort of the patient's home.
| Question | Answer |
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| Form Name | Hcsp M11 Q Form |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | m11q new york, m11q form, emblem m11q form, emblem health 11q form |
MEDICAL REQUEST FOR HOME CARE |
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HCSP- M11Q 12/09/2014 |
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GSS District Office ______________ |
Attn: Case Load No._________________________ |
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Return |
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Date Returned to/Received byGSS |
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Completed |
Address__________________________________________ |
Borough ____________________ |
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Form to: |
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Zip Code ______________________ |
Tel. No. ____________________ |
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FOR GSS USE ONLY |
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1. CLIENT INFORMATION |
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Patient’s Name |
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Birthdate |
Social Security Number |
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Medicaid No. |
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Home address (No. & Street) |
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Borough |
Zip Code |
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Telephone No. |
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Hospital/Clinic Chart No. |
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Contact Person |
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Contact Tel. No. |
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II. MEDICAL STATUS |
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PATIENT'S MEDICAL RELEASE: I hereby authorize all physicians and medical providers to release any information acquired in the course of my examination of treatment to the New York City HRA/ Dept. of Social Services in connection with my request for home care.
Date: ______________________ |
Signature(X) ________________________________________________ |
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How long have you |
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Date of this |
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Place of this |
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Date of next |
treated the patient? |
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Examination: |
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Examination: |
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Examination: |
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A. CURRENT CONDITION
Date of |
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Check( ) prognosis of each |
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Onset |
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1. |
Primary |
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Diagnosis/ ICD Code |
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2. |
Secondary |
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Diagnosis/ ICD Code |
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3.
4.
5.
Anticipated Recovery 6 months ()
Chronic Condition ( )
Deterioration of Present Function Level ()
B. HOSPITAL INFORMATION CURRENTLY IN: (Hospital Name)
Reason for
Hospitalization: ________________________________________________________
C. MEDICATION |
Dosage |
Oral or |
Frequency |
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Parenteral |
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1. |
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2. |
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3. |
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4. |
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5. |
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Admission
Date: ____________________________________
Expected Date
of Discharge:
Indicate patient’s ability to take medication: (*)
1. Can
2. Needs reminding
3. Needs supervision
4. Needs help with preparation
5. Needs administration
6.
7.
(*) If patient CANNOT |
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(a) Can he/she be trained to |
Yes |
No If no, indicate why not: __________________________________ |
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(b)What arrangements have been made for the administration of medications? _______________________________________________________
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Page 1 of 3 |
D. MEDICAL TREATMENT |
Does the patient receive any of the following medical treatment? |
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Indicate medical treatment currently received: ( ) |
Yes |
No |
1.Decubitus Care
2.Dressings: Sterile Simple
3.Bed bound Care (turning, exercising, positioning)
4.Ambulation Exercise
5.ROM/Therapeutic Exercise
6.Enema
7.Colostomy Care
8.Ostomy Care
9.Oxygen Administration
10.Catheter Care
11.Tube Irrigation
12.Monitor Vital Signs
13.Tube Feedings
14.Inhalation Therapy
15.Suctioning
16.Speech/Hearing/ Therapy
17.Occupational Therapy
18.Rehabilitation Therapy
19.Indicate any special dietary needs
20.Other
For each treatment checked, indicate frequency recommended, how the service is currently being provided and what plans have been made to provide the service in the future: (Attach additional documentation as necessary.)
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
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Based on the medical condition, do you recommend the provision of service to assist with personal care and/or light housekeeping tasks?
Yes
No
Please indicate contributing factors (e.g. limited range of motion, muscular motor impairments, etc.) and any other information that may be pertinent to the patient's need for assistance with personal care services tasks.
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
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Can patient direct a home care worker?
Yes
No If no, explain below:
____________________________________________________________________________________________________________________________________
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E. EQUIPMENT/SUPPLIES
Please indicate which equipment/supplies the client has, needs or has been ordered.
Has Needs Ordered
Cane
Crutches
Walker
Wheelchair
Hospital Bed
Side Rails
Has |
Needs |
Ordered |
Bedpan/Urinal
Commode
Diapers
Hoyer Lift
Dressings
Respiratory Aids
Has Needs Ordered
Bath Bar
Bath Seat
Grab Bar
Shower Handle
Other (Specify)
If any needed equipment was not ordered, what other plans have been made to meet this need?
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
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SSN: _________________________________
Page 2 of 3 |
F. REFERRALS
Has a referral been made to any of these agencies: Certified Home Health Agency,
Facility (HRF), a Skilled Nursing Facility (SNF) or the Lombardi Program? |
Yes |
No |
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*IDENTITY AGENCY |
SERVICE |
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STATUS OF SERVICE |
REFERRAL DATE |
__________________________________ |
__________________________________ |
__________________________________ |
___________________________________ |
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__________________________________ |
__________________________________ |
__________________________________ |
___________________________________ |
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G. ADDITIONAL COMMENTS
Describe any other aspects of the patient’s medical, social, family or home situation which affects the patient‘s ability to function, or may affect need for home care. If necessary, please attach an additional sheet(s) explaining the patient’s condition in greater detail.
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Signature of Person Completing Additional Comments Section
Title
Agency
Date
Physician’s Certification
I, the undersigned physician, certify that this patient can be cared for at home, and that I have accurately described his or her medical condition, needs and regimens, including any medication regimens, at the time I examined him or her. I understand that I am not to recommend the number of hours of personal care services this patient may require. I also understand that this physician’s order is subject to the New York State Department of Health regulations at part 515, 516, 517, and 518 of title 18 NYCRR, which permit the department to impose monetary penalties on, or sanction and recover overpayments from, providers or prescribers of medical care, services or supplies when medical care, services or supplies that are unnecessary, improper or exceed the patient’s documented medical condition are provided or ordered.
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Intern |
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Resident |
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*(PRINT) Physician’s Name |
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Specialty |
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*Physician’s Signature |
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*Business Address |
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*City |
*State |
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*Zip Code |
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Signature date must be within thirty days after medical exam of patient.
______________________ |
________________ |
____________________ |
__________________________________ |
_____________________________ |
*Date Form Completed |
*Registry Number |
*NPI Number |
*Physician’s Telephone |
Physician’s |
Indicate where form was completed: |
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___________________________________ |
________________________________________________________ |
__________________________ |
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Hospital/Clinic/Institution Name |
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Address |
Telephone No. / |
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If Nurse /Social Worker/other person assisted in completing this form:
______________________________ |
_______________________ |
________________________________________________ |
____________________________ |
Name |
Title |
Address |
Telephone No. / |
*Mandatory |
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Page 3 of 3 |
EIGHT HELPFUL HINTS FOR ACCURATE COMPLETION OF THE MEDICAL
REQUEST FOR HOME CARE (M11Q)
* Please provide this sheet to the physician filling out the Medical Request for Home Care
Eight Helpful Hints for Accurate Completion of the
Medical Request for Home Care
1.The client’s name, address and Social Security number must be provided.
2.The medical professional must complete the
3.The medical professional must not recommend or request the number of hours of personal care services.
4.The
5.The date of the examination must be provided.
6.The physician must sign and date the
7.The registry number, NPI (national provider ID), and the complete business address of the physician must be indicated.
8.The completed signed copy of the