Form Preview Example

MEDICAL REQUEST FOR HOME CARE

HCSP- M11Q 12/09/2014

GSS District Office ______________

Attn: Case Load No._________________________

Return

Date Returned to/Received byGSS

Completed

Address__________________________________________

Borough ____________________

Form to:

Zip Code ______________________

Tel. No. ____________________

FOR GSS USE ONLY

1. CLIENT INFORMATION

Patient’s Name

Birthdate

Social Security Number

Medicaid No.

Home address (No. & Street)

Borough

Zip Code

Telephone No.

Hospital/Clinic Chart No.

Contact Person

Contact Tel. No.

II. MEDICAL STATUS

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) ________________________________________________
How long have you	Date of this		Place of this	Date of next
treated the patient?	Examination:		Examination:	Examination:

A. CURRENT CONDITION

Date of		Check( ) prognosis of each
Onset
1.	Primary
	Diagnosis/ ICD Code

2.	Secondary
	Diagnosis/ ICD Code

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
C. MEDICATION	Dosage	Parenteral	Frequency
		Parenteral
1.

2.

3.

4.

5.

Admission

Date: ____________________________________

Expected Date

of Discharge:

Indicate patient’s ability to take medication: (*)

1. Can self-administer

2. Needs reminding

3. Needs supervision

4. Needs help with preparation

5. Needs administration

(*) If patient CANNOT self-administer medication
(a) Can he/she be trained to self-administer medication?	Yes	No If no, indicate why not: __________________________________

________________________________________________________________________________________________________________________

(b)What arrangements have been made for the administration of medications? _______________________________________________________

________________________________________________________________________________________________________________________

HCSP-M11-Q (12/09/2014)

Page 1 of 3

D. MEDICAL TREATMENT	Does the patient receive any of the following medical treatment?
	Indicate medical treatment currently received: ( )

Yes

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.)

_____________________________________________________________________________________________________________________________________

Based on the medical condition, do you recommend the provision of service to assist with personal care and/or light housekeeping tasks?

Yes

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.

_________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

Can patient direct a home care worker?

Yes

No If no, explain below:

____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

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?

_________________________________________________________________________________________________________________________

SSN: _________________________________

HCSP-M11-Q (12/09/2014)

Page 2 of 3

F. REFERRALS

Has a referral been made to any of these agencies: Certified Home Health Agency, Hospital-Based Home Care Agency, Hospice, a Health Related

Facility (HRF), a Skilled Nursing Facility (SNF) or the Lombardi Program?		Yes	No
*IDENTITY AGENCY	SERVICE		STATUS OF SERVICE	REFERRAL DATE
__________________________________	__________________________________	__________________________________		___________________________________
__________________________________	__________________________________	__________________________________		___________________________________

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.

_______________________________________________________________________________________________________________________

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.

Intern

Resident

*(PRINT) Physician’s Name

Specialty

*Physician’s Signature

*Business Address

*City

*State

*Zip Code

Signature date must be within thirty days after medical exam of patient.

______________________	________________	____________________	__________________________________	_____________________________
*Date Form Completed	*Registry Number	*NPI Number	*Physician’s Telephone	Physician’s E-mail
Indicate where form was completed:
___________________________________		________________________________________________________		__________________________
Hospital/Clinic/Institution Name			Address	Telephone No. / E-mail

If Nurse /Social Worker/other person assisted in completing this form:

______________________________	_______________________	________________________________________________	____________________________
Name	Title	Address	Telephone No. / E-mail
*Mandatory

HCSP-M11-Q (12/09/2014)

Page 3 of 3

EIGHT HELPFUL HINTS FOR ACCURATE COMPLETION OF THE MEDICAL

REQUEST FOR HOME CARE (M11Q)

HCSP-712b 12/09/2014

* Please provide this sheet to the physician filling out the Medical Request for Home Care (M-11Q).

Eight Helpful Hints for Accurate Completion of the

Medical Request for Home Care (M-11Q)

1.The client’s name, address and Social Security number must be provided.

2.The medical professional must complete the M-11Q by accurately describing the patient’s medical condition.

3.The medical professional must not recommend or request the number of hours of personal care services.

4.The M-11Q must be signed by a NY State licensed physician.

5.The date of the examination must be provided.

6.The physician must sign and date the M-11Q within 30 days after the exam date.

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 M-11Q must be forwarded within 30 calendar days after the medical examination.

Question	Answer
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

Hcsp M11 Q Form – Fill Out and Use This PDF

Hcsp M11 Q Form PDF Details

Form Preview Example

Hcsp M11 Q Form isn’t the one you’re looking for?

Hcsp M11 Q Form – Fill Out and Use This PDF

Hcsp M11 Q Form PDF Details

Form Preview Example

Hcsp M11 Q Form isn’t the one you’re looking for?

Related Documents