M11Q Form – Fill Out and Use This PDF

The M11Q form is a document that collects information about the nature of an individual's disability, as well as their functional limitations.

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The M11Q form is a tool that can be used to calculate the taxable value of property. The form can be used to calculate the taxable value of both real and personal property. The form can be used by individuals, businesses, and local governments. The form can be used to determine the value of property for tax purposes. The form is updated annually by the Department of Revenue. The form is available online.

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Question	Answer
Form Name	M11Q Form
Form Length	4 pages
Fillable?	Yes
Fillable fields	217
Avg. time to fill out	22 min 14 sec
Other names	m11q forms download nyc, m11q pdf, m11q medical form, m11q form print

12

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. ____________________

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

3.

4.

5.

Check( ) prognosis of each

<![endif]>Anticipated Recovery 6 months ()

<![endif]>Chronic Condition ( )

<![endif]>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

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.

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

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.

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m11q empty spaces to fill out

In the Expected, Date, of, Discharge Frequency, Parent, era, l Dosage, Oral, or and Admission, Date field, type in your data.

ExpectedDateofDischarge, Frequency, Parenteral, Dosage, Oralor, and AdmissionDate in m11q

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The D, MEDICAL, TREATMENT and Yes, No section can be used to specify the rights and obligations of either side.

m11q DMEDICALTREATMENT, and YesNo fields to fill

Complete the form by looking at all of these areas: Has, Bedpan, Urinal Needs, Ordered Yes, No If, no, explain, below HasNeeds, Ordered and Has, Needs, Ordered

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