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APPENDIX 100LEVEL OF CARE

Instructions

Community Care Services Program

LEVEL OF CARE

Purpose:   The Level Of Care (LOC) page summarizes the client’s physical, mental, social, and environmental status to help determine the client’s appropriateness for the Community Care Services Program (CCSP) or other services.  In addition, the LOC page represents the physician’s order for all waivered services provided by CCSP.

Who Completes Form: Initial assessments are completed by the RN care coordinator.  Subsequent reassessments are completed by the RN or LPN. However, the LOC is always certified by the RN care coordinator.  The client’s physician or nurse practitioner participates in all assessments and reassessments by completing designating sections of the LOC page and signing the form.

When the Form is Completed:

The RN care coordinator completes the LOC page at initial assessments and reassessments.

Instructions:

SECTION IA.  IDENTIFYING INFORMATION

Client Information in Section I is completed from information obtained from referral source or individual (patient) being referred.

1.Enter complete name, address & telephone number, including area code, of care coordination team.

2.

Enter client’s last name, first name, and middle initial, in that order, exactly as it appears on the Medicaid, Medicare, or social security card.

3.

Enter home address of client, including street number, name of street, apartment number (if applicable), or rural route and box number, town, state and zip code.

4.

Enter client’s area code and telephone number.

5.

Enter client’s county of residence.

6.

Enter planning and service area (PSA) number where client resides.

7.

Enter client’s Medicaid number exactly as it appears on the Medicaid card.

NOTE:  Potential Medical Assistance Only (PMAO) applicants do not have a current Medicaid number.  For PMAO applicants, please leave this item blank.

8.       Enter client’s nine-digit social security number.

9.  Enter client’s mother's maiden name.

MT 2005-1 12/04APPENDIX 100 page- 75

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