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 fields64
Avg. time to fill out13 min 7 sec
Other namesnc dma long term care fl2, north carolina fl2 form download, fl2, form fl2

Form Preview Example

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

 

 

 

10. CURRENT LEVEL OF CARE

11. RECOMMENDED LEVEL OF CARE

_____

HOME

_____

HOME

_____

SNF

_____

SNF

_____

ICF

_____

ICF

_____

HOSPITAL

_____

HOSPITAL

_____

DOMICILIARY (REST HOME)

_____

DOMICILIARY (REST HOME)

_____

OTHER ___________________

_____

OTHER ___________________

 

 

 

 

9. RELATIVE NAME AND ADDRESS

12. PRIOR APPROVAL NO.

14. DISCHARGE PLAN

 

_____

HOME

 

_____

SNF

13. DATE APPROVED/DENIED

_____

ICF

 

_____

HOSPITAL

 

_____

DOMICILIARY (REST HOME)

 

_____ 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

SI

 

 

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

How to Edit Nc Fl2 Form Online for Free

The PDF editor works to make filling out forms easy. It is rather an easy task to change the [FORMNAME] form. Consider these particular actions to be able to do it:

Step 1: The first task is to click on the orange "Get Form Now" button.

Step 2: The form editing page is now open. It's possible to add text or enhance existing data.

The next sections are what you are going to fill in to get your finished PDF file.

step 1 to filling in  nc fl2 form

Step 3: Once you click the Done button, your finished file can be easily transferred to all of your devices or to email indicated by you.

Step 4: Make a copy of every file. It's going to save you time and permit you to keep clear of challenges later on. Also, your information will not be revealed or analyzed by us.

Watch Nc Fl2 Form Video Instruction

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .