Physician Summary Form (PSF-1) at a glance
What it is: The Physician Summary Form is a Commonwealth of Massachusetts form for MassHealth.
Who signs: Under Provider's signature, sign and circle MD, NP or PA. Signature and date stamps, or the signature of anyone other than the provider are not acceptable.
The provider (MD, NP or PA) signs this form; the signature of anyone other than the provider is not acceptable. This form validates the medical information provided by your patient or the patient's legal guardian. This form must be returned as soon as possible. Without this information, your patient's ability to initiate or continue to receive timely MassHealth services may be impacted.
A filled-in Physician Summary Form (PSF-1) example: a physician summarizes a patient's medical information
How to fill out Physician Summary Form (PSF-1), box by box
Patient
Enter the patient's Last name, First name and Date of birth, and mark F or M under Gender.
Diagnosis(es)
Enter the Diagnosis under Diagnosis(es); the boxes are Mental illness (indicate diagnosis), Intellectual disability and Developmental disability.
Treatments, Medications and Skilled Therapy
Under Treatments, list type and frequency. Under Medications, list drug, dose, route, and frequency; use the back of the form for additional medications.
Under Skilled Therapy (Direct therapy by OT, PT, ST), enter the therapy.
Recent vital signs, Allergies, Height, Weight, Continence and Mental Status
Under Recent vital signs, enter the Date and T, P, R and BP. Under Allergies, mark No known allergies, No known drug allergies, or Allergies, list. Under Continence, for Bowel mark Continent, Incontinent or Colostomy, and for Bladder mark Continent, Incontinent or Catheter. Under Mental Status, mark Alert & oriented, Alert & disoriented or Other.
Enter the Height and the Weight.
Recent Lab work, Diet and Additional comments/Special needs
Enter Additional comments/Special needs, Recent Lab work, Diet, and the Date of last physical exam.
I recommend this patient for the following service(s)
Mark the service(s) you recommend for this patient: Adult day health (ADH), Group adult foster care (GAFC), Adult foster care (AFC), Program for All-inclusive Care for the Elderly (PACE) or Nursing facility (NF).
Provider's signature, Print name, Date completed and Print address
"I certify that the information on this form, and any attached statement that I have provided has been reviewed and signed by me, and is true, accurate, and complete, to the best of my knowledge."
Enter the Print name, the Date completed and the Print address.
Sources
[1] Physician Summary Form PSF-1 (Rev. 07/10), Executive Office of Health and Human Services, Commonwealth of Massachusetts (the Official source link on this page).