Free Medicaid Waiver Program Health Report - Wisconsin

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.

Yes

No Medications should be supervised.

(Check one.)

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

b.

Ostomy care Suctioning Transfusions Chemotherapy Catheter ­ Type: 5.

Feeding tube Parenteral / IV Severe pain Radiation

Range of motion Other ­ List below.

4.

Ongoing diagnostic tests required ­ type and frequency

Diet / nutrition ­ List special instructions

SIGNATURE ­ Physician, Physician Assistant or Registered Nurse

Date Signed

CARE MANAGER ­ See page 2

F-20810 (Rev. 08/2008)

Page 2

C.

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

Title