The necessity for accurate and comprehensive healthcare documentation is nowhere more evident than in the context of the Physician Summary Form utilized within the Commonwealth of Massachusetts. Aimed primarily at individuals receiving MassHealth services, this crucial document serves to authenticate and confirm the medical details as reported by patients or their legal guardians. Compiled by healthcare professionals, it meticulously records diagnoses, treatments, medications – including dosages and frequencies, skilled therapy sessions, and recent vital signs, alongside specific sections detailing mental and developmental conditions. Additionally, this form captures vital patient information like allergies, continence, weight, recent laboratory work, dietary needs, and mental status, ensuring a holistic representation of the patient's current health status. Beyond serving as a mere repository of health information, the Physician Summary Form is pivotal for initiating or continuing the provision of time-sensitive MassHealth services, underscoring the importance of its prompt return. Without this comprehensive verification, patients may encounter delays or obstacles in accessing the necessary services. The document further includes provisions for recommending patients for various specialized healthcare services, emphasizing the physician's role in advocating for appropriate care pathways. This underscores the collaborative effort between healthcare providers and MassHealth in catering to the nuanced needs of patients, rooted in detailed and accurate medical documentation.
Question | Answer |
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Form Name | Physician Summary Form |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | summary form make, physician form, physician form printable, massachusetts physician form |
Commonwealth of Massachusetts
Executive Ofice of Health and Human Services
www.mass.gov/masshealth
Physician Summary Form
Patient
Last name
Diagnosis
Diagnosis(es)
orm veriies and validates the medical information provided b our patient or the patient’s legal guardianorm must
be returned as soon as possibleithout this information our patient’s abilit to initiate or continue to receive timel Massalth services ma be impacted
First name |
Date of birth |
F M
Mental illness (indicate diagnosis)
ellectual disabilit |
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Developmental disabilit |
Treatments |
Medications (use back of form for additional medications) |
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List type and frequency. |
List drug, dose, route, and frequency. |
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Skilled Therapy
Direct therapy by OT, PT, ST
Recent vital signs |
Allergies |
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Date : |
T: |
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No known allergies |
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No known drug allergies |
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P: Allergies, list:
BP:
Additional comments/Special needs
Height |
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Continence |
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Bowel |
Bladder |
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Continent |
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Continent |
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Weight |
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Incontinent |
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Incontinent |
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Colostomy |
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Catheter |
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Recent Lab work |
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Diet:
Mental Status
Alert & oriented
Alert & disoriented Other:
Date of last phsical eam
Date of last oice visit
I recommend this patient for the following service(s)
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Adult da health (AD |
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oup adult foster care (AF |
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Adult foster care (AF |
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Program for Alle e for the (PA |
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Nursing facilit (NF) |
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ertif that the information on this form and an attached statement that ve provided has been revieed and signed b me and is true accurate and complete to |
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the best of m estand that be subo civil penalties or criminal prosecution for an falsiication omission or concealment of an material fact |
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contained herein |
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Provider’s signature |
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MD/NP/PA (cle one |
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(e and date stamps or the signature of anone other then the provider are not acceptable |
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Print name |
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Date completed |
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Print address