Any questions please contact 718-***-****.

Thanks!

Form Must be sent within 30 days from Date of

examination & Date signed

Please send completed forms to

Fax: 347-***-**** OR

Email: advsj0@r.postjobfree.com

FreedomCare 1979 Marcus Ave Lake Success, NY, 11042 Suite C115 P. 718-***-**** F. 347-***-**** 347-***-****

MEDICAL REQUEST FOR HOME CARE

HCSP- M11Q 12/09/2014

GSS District Office Attn: Case Load No. Date Returned to/Received byGSS

FOR GSS USE ONLY

Return

Completed

Form to:

Address Borough 1. CLIENT INFORMATION

Zip Code Tel. No. Patient’s Name Birthdate Social Security Number Medicaid No. Home address (No. & Street) Borough Zip Code Telephone No. Hospital/Clinic Chart No.

II. MEDICAL STATUS

Contact Person Contact Tel. No.

PATIENT'S MEDICAL RELEASE: I hereby authorize all physicians and medical providers to release any information acquired in the course of my examination of treatment to the New York City HRA/ Dept. of Social Services in connection with my request for home care. Date: Signature(X) How long have you

treated the patient?

Date of this

Examination:

Place of this

Examination:

Date of next

Examination:

A. CURRENT CONDITION

Date of Check prognosis of each

Onset

Anticipated

Recovery

6 months Chronic

Condition Deterioration

of Present

Function

Level 1. Primary

Diagnosis/ ICD Code

2. Secondary

Diagnosis/ ICD Code

3.

4.

5.

B. HOSPITAL INFORMATION

CURRENTLY IN: Admission

(Hospital Name) Date: Reason for

Hospitalization: Indicate patient’s ability

to take medication: C. MEDICATION Dosage Oral or

Parenteral Frequency 1. Can self-administer

1.

2. Needs reminding

2.

3. Needs supervision

3.

4. Needs help with preparation

4.

5. Needs administration

5.

6.

7. If patient CANNOT self-administer medication

(a) Can he/she be trained to self-administer medication? Yes No If no, indicate why not:

(b) What arrangements have been made for the administration of medications? HCSP-M11-Q (12/09/2014) Page 1 of 3

Expected Date

of Discharge:

*

FreedomCare 1979 Marcus Ave Lake Success, NY, 11042 Suite C115 P. 718-***-**** F. 347-***-**** 347-***-****

D. MEDICAL TREATMENT Does the patient receive any of the following medical treatment? Indicate medical treatment currently received: Yes No

1. Decubitus Care 7. Colostomy Care 15. Suctioning 2. Dressings: Sterile

Simple

8. Ostomy Care 16. Speech/Hearing/ Therapy

9. Oxygen Administration 17. Occupational Therapy

3. Bed bound Care (turning,

exercising, positioning)

10. Catheter Care 18. Rehabilitation Therapy

11. Tube Irrigation 19. Indicate any special

4. Ambulation Exercise 12. Monitor Vital Signs dietary needs 5. ROM/Therapeutic Exercise 13. Tube Feedings 20. Other 6. Enema 14. Inhalation Therapy

For each treatment checked, indicate frequency recommended, how the service is currently being provided and what plans have been made to provide the service in the future: (Attach additional documentation as necessary.) Based on the medical condition, do you recommend the provision of service to assist with personal care and/or light housekeeping tasks? Yes No

Please indicate contributing factors (e.g. limited range of motion, muscular motor impairments, etc.) and any other information that may be pertinent to the patient's need for assistance with personal care services tasks. Can patient direct a home care worker? Yes No If no, explain below: E. EQUIPMENT/SUPPLIES

Please indicate which equipment/supplies the client has, needs or has been ordered. Has Needs Ordered Has Needs Ordered Has Needs Ordered Cane Bedpan/Urinal Bath Bar

Crutches Commode Bath Seat

Walker Diapers Grab Bar

Wheelchair Hoyer Lift Shower Handle

Hospital Bed Dressings Other (Specify)

Side Rails Respiratory Aids

If any needed equipment was not ordered, what other plans have been made to meet this need? SSN:

HCSP-M11-Q (12/09/2014) Page 2 of 3

FreedomCare 1979 Marcus Ave Lake Success, NY, 11042 Suite C115 P. 718-***-**** F. 347-***-**** 347-***-****

F. REFERRALS

Has a referral been made to any of these agencies: Certified Home Health Agency, Hospital-Based Home Care Agency, Hospice, a Health Related Facility (HRF), a Skilled Nursing Facility (SNF) or the Lombardi Program? Yes No

*IDENTITY AGENCY SERVICE STATUS OF SERVICE REFERRAL DATE

G. ADDITIONAL COMMENTS

Describe any other aspects of the patient’s medical, social, family or home situation which affects the patient‘s ability to function, or may affect need for home care. If necessary, please attach an additional sheet(s) explaining the patient’s condition in greater detail. Signature of Person Completing Additional Comments Section Title Date Agency

Physician’s Certification

I, the undersigned physician, certify that this patient can be cared for at home, and that I have accurately described his or her medical condition, needs and regimens, including any medication regimens, at the time I examined him or her. I understand that I am not to recommend the number of hours of personal care services this patient may require. I also understand that this physician’s order is subject to the New York State Department of Health regulations at part 515, 516, 517, and 518 of title 18 NYCRR, which permit the department to impose monetary penalties on, or sanction and recover overpayments from, providers or prescribers of medical care, services or supplies when medical care, services or supplies that are unnecessary, improper or exceed the patient’s documented medical condition are provided or ordered. Intern Resident

*(PRINT) Physician’s Name Specialty *Physician’s Signature

*Business Address *City *State *Zip Code

Signature date must be within thirty days after medical exam of patient.

*Date Form Completed *Registry Number *NPI Number *Physician’s Telephone Physician’s E-mail Indicate where form was completed:

Hospital/Clinic/Institution Name Address Telephone No. / E-mail If Nurse /Social Worker/other person assisted in completing this form: Name Title Address Telephone No. / E-mail

*Mandatory

HCSP-M11-Q (12/09/2014) Page 3 of 3

FreedomCare 1979 Marcus Ave Lake Success, NY, 11042 Suite C115 P. 718-***-**** F. 347-***-**** 347-***-****

EIGHT HELPFUL HINTS FOR ACCURATE COMPLETION OF THE MEDICAL REQUEST FOR HOME CARE (M11Q)

HCSP-712b 12/09/2014

* Please provide this sheet to the physician filling out the Medical Request for Home Care (M-11Q). Eight Helpful Hints for Accurate Completion of the Medical Request for Home Care (M-11Q)

1. The client’s name, address and Social Security number must be provided. 2. The medical professional must complete the M-11Q by accurately describing the patient’s medical condition.

3. The medical professional must not recommend or request the number of hours of personal care services.

4. The M-11Q must be signed by a NY State licensed physician. 5. The date of the examination must be provided.

6. The physician must sign and date the M-11Q within 30 days after the exam date. 7. The registry number, NPI (national provider ID), and the complete business address of the physician must be indicated.

8. The completed signed copy of the M-11Q must be forwarded within 30 calendar days after the medical examination.

Contact this candidate