Nc Fl2 Form PDF Details

Nc Fl2 Form is a document that must be filed with the North Carolina Department of Revenue if you are a business owner or self-employed individual. The form is used to report payments and income from services rendered in the state of North Carolina. If you're not sure whether or not you need to file Nc Fl2 Form, contact the Department of Revenue for more information. The form can be filed online, or through the mail. Instructions on how to file can be found on the Department of Revenue's website. Filing deadline is January 31st each year. There is a late filing penalty if the form isn't submitted by the due date.

You will discover additional information about the nc fl2 form by looking through the table our team prepared for you.

QuestionAnswer
Form NameNc Fl2 Form
Form Length1 pages
Fillable?Yes
Fillable fields125
Avg. time to fill out25 min 19 sec
Other namesnc dma long term care fl2, north carolina fl2 form download, form care home, nc fl2

Form Preview Example

Print Form

Adult Care Home FL2 Form

 

 

 

PRIOR APPROVAL

 

 

 

UTILIZATION REVIEW

 

 

ON-SITE REVIEW

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IDENTIFICATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. PATIENT’S LAST NAME

FIRST

MIDDLE

2. BIRTHDATE (M/D/Y)

 

3. SEX

 

4. ADMISSION DATE (CURRENT LOCATION)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. COUNTY AND MEDICAID NUMBER

 

 

 

 

 

6. FACILITY

 

 

ADDRESS

 

 

7. PROVIDER NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. ATTENDING PHYSICIAN NAME AND ADDRESS

 

 

 

9. RELATIVE NAME AND ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10. CURRENT LEVEL OF CARE

 

 

11. RECOMMENDED LEVEL OF CARE

 

12. PRIOR APPROVAL NO.

 

 

 

 

14. DISCHARGE PLAN

 

 

 

 

 

HOME

 

 

 

HOME

 

 

 

 

 

 

 

 

 

 

 

 

 

HOME

 

 

 

 

 

SNF

 

 

 

SNF

 

 

 

 

 

 

 

 

 

 

 

 

 

SNF

 

 

 

 

 

ICF

 

 

 

ICF

 

 

 

13. DATE APPROVED/DENIED

 

 

 

 

 

 

ICF

 

 

 

 

 

HOSPITAL

 

 

 

HOSPITAL

 

 

 

 

 

 

 

 

 

 

 

 

HOSPITAL

 

 

 

 

 

DOMICILIARY (REST HOME)

 

 

 

DOMICILIARY (REST HOME)

 

 

 

 

 

 

 

 

 

 

 

DOMICILIARY (REST HOME)

 

 

 

OTHER

 

 

 

 

OTHER

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15. ADMITTING DIAGNOSES – PRIMARY, SECONDARY, DATES OF ONSET

 

 

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

5.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

6.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

 

 

7.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

 

 

 

8.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16. PATIENT INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DISORIENTED

 

AMBULATORY STATUS

 

 

BLADDER

 

 

 

 

BOWEL

 

 

 

 

 

 

CONSTANTLY

 

AMBULATORY

 

 

 

CONTINENT

 

 

 

 

 

CONTINENT

 

 

 

 

INTERMITTENTLY

 

SEMI-AMBULATORY

 

 

 

INCONTINENT

 

 

 

 

 

INCONTINENT

 

 

 

 

INAPPROPRIATE BEHAVIOR

 

NON-AMBULATORY

 

 

 

INDWELLING CATHETER

 

 

 

 

 

COLOSCOPY

 

 

 

 

WANDERER

 

FUNCTIONAL LIMITATIONS

 

 

EXTERNAL CATHETER

 

 

 

 

RESPIRATION

 

 

 

 

VERBALLY ABUSIVE

 

SIGHT

 

 

COMMUNICATION OF NEEDS

 

 

 

NORMAL

 

 

 

 

INJURIOUS TO SELF

 

HEARING

 

 

 

VERBALLY

 

 

 

 

 

TRACHEOSTOMY

 

 

 

 

INJURIOUS TO OTHERS

 

SPEECH

 

 

 

NON-VERBALLY

 

 

 

 

 

OTHER

 

 

 

 

 

 

INJURIOUS TO PROPERTY

 

CONTRACTURES

 

 

 

DOES NOT COMMUNICATE

 

02

 

PRN

CONT

 

 

OTHER:

 

ACTIVITIES/SOCIAL

 

 

SKIN

 

 

 

 

NUTRITION STATUS

 

 

 

 

PERSONAL CARE ASSISTANCE

 

PASSIVE

 

 

 

NORMAL

 

 

 

 

 

DIET

 

 

 

 

 

 

BATHING

 

ACTIVE

 

 

 

OTHER:

 

 

 

 

 

SUPPLEMENTAL

 

 

 

 

FEEDING

 

GROUP PARTICIPATION

 

 

DECUBITI-DESCRIBE:

 

 

 

 

 

SPOON

 

 

 

 

 

 

DRESSING

 

RE-SOCIALIZATION

 

 

 

DRESSINGS:

 

 

 

 

 

PARENTERAL

 

 

 

 

TOTAL CARE

 

FAMILY SUPPORTIVE

 

 

 

 

 

 

 

 

 

NASOGASTRIC

 

 

 

 

PHYSICIAN VISITS

 

NEUROLOGICAL

 

 

 

 

 

 

 

 

 

 

GASTROSTOMY

 

 

 

 

30 DAYS

 

CONVULSIONS/SEIZURES

 

 

 

 

 

 

 

 

 

INTAKE AND OUTPUT

 

 

 

 

60 DAYS

 

GRAND MAL

 

 

 

 

 

 

 

 

 

 

FORCE FLUIDS

 

 

 

 

OVER 180 DAYS

 

PETIT MAL

 

 

 

 

 

 

 

 

 

 

WEIGHT

 

 

 

 

 

 

 

 

FREQUENCY

 

 

 

 

 

 

 

 

 

 

HEIGHT

 

 

 

 

 

 

 

17. SPECIAL CARE FACTORS

 

FREQUENCY

 

 

SPECIAL CARE FACTORS

 

 

 

 

 

 

FREQUENCY

 

 

BLOOD PRESSURE

 

 

 

 

 

 

 

 

BOWEL AND BLADDER PROGRAM

 

 

 

 

 

 

 

 

 

 

 

 

DIABETIC URINE TESTING

 

 

 

 

 

 

 

 

RESTORATIVE FEEDING PROGRAM

 

 

 

 

 

 

 

 

 

 

 

 

PT (BY LICENSED PT)

 

 

 

 

 

 

 

 

SPEECH THERAPY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RANGE OF MOTION EXERCISES

 

 

 

 

 

 

 

 

RESTRAINTS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18. MEDICATIONS/NAME & STRENGTH, DOSAGE & ROUTE

 

 

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

7.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

8.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

 

 

9.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

 

 

 

10.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

 

 

 

 

 

 

 

 

 

 

11.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

 

 

 

 

 

 

 

 

 

 

12.

 

 

 

 

 

 

 

 

 

 

 

 

 

19.X-RAY AND LABORATORY FINDINGS/DATE: 20: ADDITIONAL INFORMATION

21. PHYSICIAN’S SIGNATURE

DATE

9.2018 NC Medicaid 372-124

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Complete the DISORIENTED, CONSTANTLY INTERMITTENTLY, INAPPROPRIATE BEHAVIOR, WANDERER VERBALLY ABUSIVE, PERSONAL CARE ASSISTANCE, BATHING FEEDING DRESSING TOTAL CARE, AMBULATORY STATUS, AMBULATORY SEMIAMBULATORY, FUNCTIONAL LIMITATIONS, SIGHT HEARING SPEECH CONTRACTURES, PATIENT INFORMATION BLADDER, CONTINENT INCONTINENT INDWELLING, COMMUNICATION OF NEEDS, VERBALLY NONVERBALLY DOES NOT, and ACTIVITIESSOCIAL areas with any particulars which may be requested by the system.

part 2 to completing nc dma long term care fl2

It's important to note specific details in the box XRAY AND LABORATORY FINDINGSDATE, ADDITIONAL INFORMATION, PHYSICIANS SIGNATURE, DATE, and NC Medicaid.

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