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APPENDIX 100LEVEL OF CARE

10, 11, 12.      Enter client’s sex ("M" or "F"), age, and date of birth (month/day/year).

13.

Enter client’s race as follows:

A = Asian/Pacific Islander               H = Hispanic               W = White

B = Black                                       NA = Native American

14.

  Enter client’s marital status as follows:

S = Single                                     M = Married                 W = Widowed

D = Divorced                             SP = Separated

15.

 Check () appropriate type of recommendation:

1.Initial:  First referral to CCSP or re-entry into CCSP after termination

2.Reassessment:  Clients requiring annual recertification or reassessment because of change in status.

16.

 Enter referral source by name and title (if applicable), or agency and type as follows:

MD = Doctor                         S = Self                                   HHA = Home health agency

NF = Nursing facility                 FM = Family                           PCH = Personal Care Home

HOSP = Hospital                       ADH = Adult Day Health       APS= Adult Protective Services     

O = Other (Identify fully)          DFCS = Division of Family & Children Services

17, 18.        Client signs and dates in spaces provided.  If client is unable to sign, spouse, parent, other relative, or legal/authorized representative may sign and note relationship to client after signature.

NOTE:  This signature gives client's physician permission to release information to care coordinator regarding level of care determination.

SECTION I B.  PHYSICIAN'S EXAMINATION REPORT AND DOCUMENTATION

Section B is completed and signed by licensed medical person completing medical report.

19.

The licensed physician/ nurse practitioner enters client’s primary, secondary, and other (if applicable) diagnoses. * The primary diagnosis should support CCSP eligibility.

NOTE: After the physician/ nurse practitioner returns signed LOC page, care coordination team  

              indicates ICD codes.  Enter ICD codes for “primary diagnosis”, “secondary diagnosis” or

              “third diagnosis” in the appropriate box.  Care coordination teams secure codes from ICD

              code book, local hospitals or client's physician.

20.

The physician/ nurse practitioner checks appropriate box to indicate if client is free of communicable diseases.

21.

List all medications, including over-the-counter (OTC) medications and state dosage, how the medications are dispensed, frequency, and reason for medication.  Attach additional sheets if necessary and reference.

MT 2010-1  8/09Appendix 100 page 76

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