OCDD Form 90 L

What are/were the living arrangements F Relationship Own home Relative s home Other E. What previous facility care has this person received Facility Date F. What Home/Community-based services have been used/considered NOW CC Supports ROW Other G. Applicant/Responsible Party Signature Date II. LEVEL OF CARE The attending physician /designee for NOW must approve the required level of care A. B. OCDD Form 90-L Rev. 06/01/2017 REQUEST FOR MEDICAL ELIGIBILITY DETERMINATION Intellectual/Developmental Disability Level of Care I. RECIPIENT INFORMATION A. Recipient s Name SS B. Address City State Zip Code Parish C. Responsible Party/Curator Medicaid Telephone Sex M Medicare Date of Birth D. What are/were the living arrangements F Relationship Own home Relative s home Other E. What previous facility care has this person received Facility Date F. What Home/Community-based services have been used/considered NOW CC Supports ROW Other G. Applicant/Responsible Party Signature Date II. Oriented 2. Forgetful 3. Depressed E. Communications Verbal 4. Comatose 5. Confused 6. Wanders 7. Hostile 8. Combative Non-verbal F. Activities of Daily Living check appropriate box SELF ASSIST TOTAL Eating Bathing Personal Ambulation Transfer Bowel Incontinence Bladder Incontinence Urinary Catheter 9. Impaired vision Glasses 10. Impaired hearing Hearing Aid 11. Dentures G. SPECIAL CARE/PROCEDURES check appropriate box when appropriate give type frequency size stage and site 1. Mental Status/Behavior check Yes or No. If Yes indicate frequency 1 seldom 2 frequent 3 always Yes 1 2 3 1. Oriented 2. Forgetful 3. Depressed E. Communications Verbal 4. Comatose 5. Confused 6. Wanders 7. Hostile 8. Ostomy care 2. Glucose Monitoring 3. Restraints 4. IV s 5. Suctioning 6. Specialized Rehab 7. MRSA/Infections 8. Diet/Tube Feeding 9. Dialysis 10. Respiratory 11. Wound Care/Decubitus 12. Tracheostomy Care 13. Ventilator Dependent 14. ICF/ID - Requires active treatment of developmental disability under supervision of a qualified intellectual / developmental disability professional. Skilled Care maximum care required Indicate special level if needed TDC ID NRTP Complex Rehab Includes professional nursing care and assessment on a daily basis due to a serious condition which is unstable or a rehabilitative therapeutic regime requiring professional staff. C. Other H. PHYSICAL EXAMINATION HeightWeightPulseRespTempB/P Lab Results HCTHGBU/A Radiology General Head and CNS Mouth and EENT Chest Heart and Circulation Abdomen Genitalia Extremities Skin Other I. RECIPIENT INFORMATION A. Recipient s Name SS B. Address City State Zip Code Parish C. Responsible Party/Curator Medicaid Telephone Sex M Medicare Date of Birth D. Mental Status/Behavior check Yes or No* If Yes indicate frequency 1 seldom 2 frequent 3 always Yes 1 2 3 1. MD Signature is required EXCEPT for the NOW program* The NOW can have a Nurse Practitioner/Physician Assistant signature.