Masshealth Request Services Form PDF Details

In October 2002, the Commonwealth of Massachusetts, through its Executive Office of Health and Human Services and the Division of Medical Assistance, introduced a significant update to its healthcare documentation process for PACE (Program for All-Inclusive Care of the Elderly) providers with the revision of the Request for Services Form. This change, spearheaded by Commissioner Wendy E. Warring, was designed to streamline communication between healthcare providers and the Division, ensuring that the clinical eligibility of applicants and members for various services could be assessed more effectively. The form, which must be filled out by a registered nurse, encompasses requests for a broad spectrum of services such as pre-admission to nursing facilities, home and community-based services waivers, adult day health, adult foster care, and several others. It requires detailed information about the member or applicant, including their physical and mental health status, to enable a comprehensive review of their needs. This document has become a crucial tool in facilitating access to necessary health services for the elderly and those with specific healthcare needs, emphasizing the state's commitment to responsive and inclusive healthcare provision.

QuestionAnswer
Form NameMasshealth Request Services Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesrfs 1 masshealth form request for services, rfs 1, masshealth representative authorization form, masshealth request for services form

Form Preview Example

COMMONWEALTH OF MASSACHUSETTS

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

DIVISION OF MEDICAL ASSISTANCE

600 Washington Street Boston, MA 02111 www.mass.gov/dma

MassHealth

PACE Bulletin 1

October 2002

TO: PACE (Program for All-Inclusive Care of the Elderly) Providers Participating in MassHealth

FROM: Wendy E. Warring, Commissioner

RE:

Request for Services Form

 

 

 

 

Revision to Request for

The Request for Services form (formerly called the MassHealth Long

Services Form

Term Care Assessment form for PACE providers) has been revised in an

 

effort to facilitate communication between providers and the Division.

 

Effective October 1, 2002, the Division or its agent will accept only the

 

revised Request for Services form. To determine the applicant’s or

 

member’s clinical eligibility, PACE providers must complete this form and

 

submit it with the Minimum Data Set (MDS-HC) to their local Aging

 

Services Access Points (ASAPs), the Division’s agent.

 

 

Completing the Form

A nurse, licensed by the Massachusetts Board of Registration in Nursing

 

as a registered nurse, must complete the Request for Services form.

 

 

Obtaining the Form

A copy of the Request for Services form is attached. You may photocopy

 

the form as needed. To obtain supplies of the form, mail or fax a written

 

request to the following address or fax number.

 

MassHealth

 

Forms Distribution

 

P.O. Box 9101

 

Somerville, MA 02145

 

Fax: 617-576-4087

 

 

Effective Date

You must begin using this form by October 1, 2002. Please discard all

 

previous versions of this form.

 

 

Questions

If you have any questions about this bulletin, please contact MassHealth

 

Provider Services at 617-628-4141 or 1-800-325-5231.

 

 

 

 

Request for Services

Type of clinical eligibility determination all requested services.

Service(s) requested

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pre-admission nursing facility (NF)

Home and community

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

based services (HCBS) waiver

 

 

Adult day health (ADH)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Adult foster care (AFC)

 

 

 

 

Program for All-inclusive Care

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

for the Elderly (PACE)

 

 

Group adult foster care (GAFC)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

Date

Nursing facility use only

Conversion

Continued stay

Short term review

Transfer NF to NF

Retrospective

Member information

Member/applicant

Last name

First name

Telephone

Address

City

Zip

Check one

 

 

 

 

 

 

 

 

MassHealth

 

 

MassHealth

 

 

GAFC/

 

 

 

 

 

 

 

member

 

 

application pending

 

 

Assisted living residence

 

 

 

 

 

 

 

 

 

 

 

 

 

MassHealth ID number

 

Date application iled

 

 

Date SSI-G application iled

Next of kin/Responsible party

 

 

 

 

 

 

 

Last name

 

First name

Telephone

Address

City

Zip

Physician

Last name

 

First name

Telephone

Address

City

Zip

Screening for mental illness, mental retardation, and developmental disability

Does the member/applicant have any of the following diagnoses/conditions? Check all that apply.

 

Mental illness

 

Specify:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mental retardation without related condition

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Developmental disability with related condition that occurred prior to age 22.

Check all that apply.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Autism

 

 

 

 

 

 

 

 

Deafness/severe hearing impairment

 

Multiple sclerosis

 

 

 

 

Severe learning disability

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Blindness/severe visual impairment

Epilepsy/seizure disorder

 

 

 

 

 

 

 

 

Muscular dystrophy

 

 

 

Spina biida

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cerebral palsy

 

Head/brain injury

 

 

 

Orthopedic impairment

 

 

Spinal cord injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Major mental illness

 

 

 

 

 

 

 

 

Cystic ibrosis

 

 

 

Speech/language impairment

 

 

 

 

 

RFS-1 (Rev. 10/02)

OVER

Name of member/applicant

Community services recommended

Check all that apply.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Skilled nursing

 

 

 

 

 

 

HCBS waiver

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rest home

Homemaker

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physical therapy

Elderly housing

 

 

 

 

 

 

Personal emergency response system

 

 

 

 

 

 

 

 

 

 

 

Meals

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Occupational therapy

 

 

 

 

Adult foster care

 

 

 

Adult day health

 

 

 

Transportation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Speech therapy

 

 

 

 

 

 

Group adult foster care

 

 

PACE

 

 

 

Chore service

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mental health services

Home health aide

Grocery shopping/delivery

 

 

Assisted living

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social worker services

 

 

 

Congregate housing

 

 

 

 

 

 

Personal care/homemaker

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional information

1. Is the home or apartment available for the member or applicant?

 

 

 

 

yes

 

no

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

yes

 

no

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Is there a caregiver to assist the member in the community?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

yes

 

no

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Has the member or applicant experienced unexplained weight gain in the last 30 days?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

yes

 

no

4.

Does the member or applicant receive personal care/homemaker services?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes:

days per week

 

 

hours per week

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

no

5.

Has the member or applicant experienced a signiicant change in condition in the last 30 days?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes:

 

 

 

 

improvement

 

 

 

 

 

deterioration

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Indicate the changes below.

For nursing facility requests only

1.Does the nursing facility member/applicant express an interest to remain in or return to the community?

2.Is the nursing facility stay expected to be short-term (up to 90 days)?

3.Is the nursing facility stay expected to be long-term (more than 90 days)?

Referral source Name of registered nurse completing this form

Signature

 

 

Print name

 

 

 

 

 

 

 

 

yes

no

yes

no

yes

no

Title

Name of organization

Telephone

Address

City

Zip

For community providers:

For nursing facility providers:

Attach the MDS-HC and Physician’s Summary form according to provider’s regulations/guidelines.

Attach the most recent comprehensive MDS, current quarterly MDS, and current physician orders.

How to Edit Masshealth Request Services Form Online for Free

Using the online editor for PDFs by FormsPal, you're able to fill out or edit masshealth request for services here. Our expert team is constantly endeavoring to enhance the tool and ensure it is much faster for clients with its many functions. Make use of today's progressive opportunities, and find a trove of emerging experiences! To begin your journey, consider these easy steps:

Step 1: Hit the "Get Form" button at the top of this webpage to open our PDF tool.

Step 2: The editor will allow you to customize most PDF files in a variety of ways. Change it by writing any text, correct what is already in the PDF, and add a signature - all readily available!

With regards to the blanks of this precise PDF, here's what you should do:

1. To get started, while completing the masshealth request for services, start in the part containing next blanks:

How to prepare rfs request services form portion 1

2. The third stage is to submit all of the following blanks: MassHealth member, MassHealth application pending, GAFC Assisted living residence, MassHealth ID number, Date application i led, Date SSIG application i led, Next of kinResponsible party, Last name, Address, Physician, Last name, Address, First name, First name, and Telephone.

How to complete rfs request services form step 2

3. Within this part, look at Developmental disability with, Deafnesssevere hearing impairment, Autism, Severe learning disability, Blindnesssevere visual impairment, Epilepsyseizure disorder, Muscular dystrophy, Spina bii da, Cerebral palsy, Cystic i brosis, Headbrain injury, Major mental illness, Orthopedic impairment, Spinal cord injury, and Speechlanguage impairment. All these will need to be filled in with utmost precision.

Deafnesssevere hearing impairment, Severe learning disability, and Cerebral palsy of rfs request services form

4. The form's fourth paragraph comes next with these blank fields to type in your specifics in: Community services recommended, Name of memberapplicant, Check all that apply, Skilled nursing, Physical therapy, HCBS waiver, Rest home, Personal emergency response system, Elderly housing, Occupational therapy, Adult foster care, Adult day health, Speech therapy, Group adult foster care, and PACE.

Step # 4 of filling out rfs request services form

A lot of people generally make some errors while filling in HCBS waiver in this section. You should double-check what you type in here.

5. This pdf should be wrapped up by dealing with this area. Here you have a comprehensive set of blank fields that have to be filled in with specific details to allow your document usage to be faultless: Has the member or applicant, Does the member or applicant, If yes, days per week, hours per week, yes, yes, Has the member or applicant, yes, If yes, improvement deterioration, Indicate the changes below, For nursing facility requests only, Does the nursing facility, and return to the community.

Tips on how to fill out rfs request services form step 5

Step 3: Confirm that your details are correct and click "Done" to continue further. Create a free trial account at FormsPal and obtain direct access to masshealth request for services - downloadable, emailable, and editable from your personal account. When you use FormsPal, you're able to fill out forms without worrying about information breaches or records being distributed. Our protected platform ensures that your personal data is kept safely.