DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-20810 (Rev. 08/2008)
STATE OF WISCONSIN
MEDICAID WAIVER PROGRAM HEALTH REPORT
Use of form: Personally identifiable information collected on this form is confidential and will be used for identification purposes and to document the individual's health information necessary in determining eligibility for services. Completion of this form is necessary to meet the requirements of Wis. Stats. 46.27(11) and 46.277(4). Instructions: Complete within 90 days (before or after) the Waiver Start Date and annually within 90 days (before or after) the Waiver recertification month for each CIP II or COP-W participant. A. TO BE COMPLETED BY CARE MANAGER Name Participant (Last, First, MI) Name County Agency / Care Manager Name Physician / Clinic / Office Physician's Telephone Number
Date of Birth (mm/dd/yyyy)
B. TO BE COMPLETED BY PHYSICIAN OR REGISTERED NURSE 1. Describe participant's diagnosis (i.e., disabilities / impairments / rehabilitation potential / prognosis). List primary diagnosis first. If necessary, attach additional documentation.)
1a. Condition is considered: Stable Unstable (Check one.) 2. List name of medications, dosage and frequency. Include injections, prescription and over-the-counter medications ordered. If necessary, attach additional documentation.
2a. 3. a.
No Medications should be supervised.
Physician's Orders Therapies / home health Home nursing care Occupational therapy Physical therapy Treatments Oxygen Dialysis IV meds Decubiti care Ventilator
(Check all that apply.) Home health aide Speech therapy Assistance with housekeeping / chores
Personal care Other
Ostomy care Suctioning Transfusions Chemotherapy Catheter Type: 5.
Feeding tube Parenteral / IV Severe pain Radiation
Range of motion Other List below.
Ongoing diagnostic tests required type and frequency
Diet / nutrition List special instructions
SIGNATURE Physician, Physician Assistant or Registered Nurse
CARE MANAGER See page 2
F-20810 (Rev. 08/2008)
COMPLETION OF ITEMS 1 AND 2 BELOW ARE OPTIONAL.
If part C is completed, the information should be provided by the care manager, nurse or another professional familiar with this applicant / participant. Enter information not found on the Long Term Care Functional Screen or the Assessment / Supplement, or that is missing from page one of this form. 1. Describe mobility / activity limitations. List DME or adaptive aids needed.
2. Other relevant information: Mental status, orientation, communication, social abilities, special health needs or other applicant / participant-specific information that substantiates the level of care determination.
Name Person filling out part C