Free Form 02AG001E (ABCDM-83-A) - Oklahoma

*02AG001E-001*
OKLAHOMA DEPARTMENT OF HUMAN SERVICES

Request for Title XIX Nursing Assessment
Form 02AG001E is completed by the intermediate care facility (ICF) to notify OKDHS of a Medicaid client's admission into the ICF and request a nursing assessment by the long-term care (LTC) nurse.

Resident information:
Last name Client identification (ID) number Date of birth Gender Male M.I. First Social Security number Case number Female Yes No Primary language

Is the resident able to participate in the assessment process?

Facility information:
Date of ICF admission Private pay requesting Medicaid? Yes No Facility name Address ADvantage respite: Facility certified for ADvantage respite? Physician M.D. Address D.O. Phone Effective date Phone Facility number Yes Yes No No Date of discharge

Person to contact for information:
Name Address Phone Legal guardian? Yes No Power of attorney? Yes No Page 1 of 2 Relationship to resident

OKDHS issued 11-10-2006

02AG001E (ABCDM-83-A)

02AG001E (ABCDM-83-A) Name Address

Request for Title XIX Nursing Assessment Relationship to resident Phone

Comments:

OKDHS use only: Information received by Referral forwarded to RN date

Date Date received by LTC nurse

Nursing facility: Mail, fax, or hand carry to the OKDHS county office

Page 2 of 2

OKDHS issued 11-10-2006