M11Q Form – Fill Out and Use This PDF

The M11Q form, also known as the Medical Request for Home Care, is a document required by the New York City Human Resources Administration/Department of Social Services. It is designed for use by medical professionals to outline a patient's health condition and the necessity for home care services, ensuring these needs are communicated accurately to the relevant authorities. For those considering or needing home care services in New York City, understanding and properly filling out this form is a crucial step. Click the button below to learn more about filling out the M11Q form.

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M11Q Form PDF Details

Understanding the MEDICAL REQUEST FOR HOME CARE, also known as the HCSP-M11Q form, is crucial for individuals seeking home care services through New York City's Human Resources Administration/Department of Social Services. Dated December 9, 2014, this comprehensive document facilitates the assessment and authorization process of home care services based on a patient's medical needs. The form is meticulously structured to capture all necessary details, starting from the client's personal information to their intricate medical status, including primary and secondary diagnoses, current medications, and any medical treatments received. It emphasizes the significance of a detailed medical release, allowing physicians and medical providers to furnish relevant information to the HRA/Dept. of Social Services, ensuring a well-informed review process. The M11Q sheds light on the patient's capacity to take medication, their ability to self-administer, and whether any special arrangements are needed. It further explores the patient's medical treatments, equipment needs, and referrals to other care agencies, ultimately assessing whether the patient's condition warrants home care services. Accompanied by helpful tips for accurate completion, the form must be carefully filled out by a licensed New York State physician, who certifies the patient's home care necessity without specifying service hours, adhering to state health regulations. This detailed approach underscores the form's crucial role in aligning patient needs with appropriate home care services, fostering a tailored care arrangement.

Question	Answer
Form Name	M11Q Form
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	form m11q, mq11 form, m11q print, m 11q

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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. ____________________

1. CLIENT INFORMATION

FOR GSS USE ONLY

Patient’s Name

Birthdate

Social Security Number

Medicaid No.

Home address (No. & Street)

Borough

Zip Code

Telephone No.

Hospital/Clinic Chart No.

II. MEDICAL STATUS

Contact Person

Contact Tel. No.

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

Onset

1. Primary

Diagnosis/ ICD Code

2. Secondary

Diagnosis/ ICD Code

Check( ) prognosis of each

Anticipated Recovery 6 months ()

Chronic Condition ( )

Deterioration of Present Function Level ()

B. HOSPITAL INFORMATION
	CURRENTLY IN:				Admission
	CURRENTLY IN:				Admission
	(Hospital Name)				Date: ____________________________________
	(Hospital Name)				Date: ____________________________________
Reason for					Expected Date
Reason for					of Discharge:
Hospitalization: ________________________________________________________					of Discharge:

							Indicate patient’s ability
							to take medication: (*)
C. MEDICATION		Dosage	Oral or	Frequency		1.	Can self-administer
C. MEDICATION		Dosage	Parenteral	Frequency
			Parenteral
1.						2.	Needs reminding
						2.	Needs reminding
2.						3.	Needs supervision
						3.	Needs supervision
3.						4.	Needs help with preparation
						4.	Needs help with preparation
4.						5.	Needs administration
						5.	Needs administration
5.

6.

7.

(*)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?			Yes		No
		Indicate medical treatment currently received: ( )


1.	Decubitus Care		7. Colostomy Care			15.	Suctioning

2.	Dressings: Sterile		8.	Ostomy Care		16.	Speech/Hearing/ Therapy
	Simple
	Simple		9.	Oxygen Administration		17.	Occupational Therapy

3.	Bed bound Care (turning,		10.	Catheter Care		18.	Rehabilitation Therapy
	exercising, positioning)
	exercising, positioning)		11.	Tube Irrigation		19.	Indicate any special
							dietary needs
4.	Ambulation Exercise		12.	Monitor Vital Signs			dietary needs

5.	ROM/Therapeutic Exercise		13.	Tube Feedings		20.	Other

6.	Enema		14.	Inhalation Therapy

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.

How to Edit M11Q Form Online for Free

Filling in mq11 form is straightforward. We developed our tool to make it intuitive and assist you to complete any PDF online. Here are a few steps that you need to go through:

Step 1: You can choose the orange "Get Form Now" button at the top of this page.

Step 2: It's now possible to modify the mq11 form. The multifunctional toolbar lets you insert, eliminate, modify, and highlight content or undertake other commands.

The next areas will compose the PDF template that you will be creating:

In the Primary Diagnosis ICD Code, B HOSPITAL INFORMATION CURRENTLY, Admission Date, Reason for Hospitalization, Expected Date of Discharge, Indicate patients ability to take, C MEDICATION, Dosage, Oral or Parenteral, Frequency, Can selfadminister, Needs reminding, Needs supervision, Needs help with preparation, and Needs administration field, type in your data.

Primary Diagnosis ICD Code, B HOSPITAL INFORMATION CURRENTLY, Admission Date, Reason for Hospitalization, Expected Date of Discharge, Indicate patients ability to take, C MEDICATION, Dosage, Oral or Parenteral, Frequency, Can selfadminister, Needs reminding, Needs supervision, Needs help with preparation, and Needs administration in how to m11q

The application will demand you to give particular vital particulars to effortlessly submit the field b What arrangements have been made, and HCSPMQ Page of.

The D MEDICAL TREATMENT, Does the patient receive any of, Yes No, Decubitus Care, Dressings Sterile, Simple, Bed bound Care turning, exercising positioning, Ambulation Exercise, ROMTherapeutic Exercise, Enema, Colostomy Care, Ostomy Care, Oxygen Administration, and Catheter Care section can be used to specify the rights and obligations of either side.

how to m11q D MEDICAL TREATMENT, Does the patient receive any of, Yes No, Decubitus Care, Dressings Sterile, Simple, Bed bound Care turning, exercising positioning, Ambulation Exercise, ROMTherapeutic Exercise, Enema, Colostomy Care, Ostomy Care, Oxygen Administration, and Catheter Care fields to fill

Complete the form by looking at all of these areas: Please indicate contributing, Can patient direct a home care, Yes No, If no explain below, E EQUIPMENTSUPPLIES, Please indicate which, Has Needs Ordered, Has, Needs Ordered, Has Needs Ordered, Cane, Crutches, Walker, Wheelchair, and Hospital Bed.

Step 3: As soon as you are done, click the "Done" button to transfer the PDF file.

Step 4: Get duplicates of the template. This may save you from upcoming complications. We cannot check or share the information you have, thus be certain it will be safe.

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