Free ForwardHealth Personal Care Addendum, F11136 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11136 (10/08)

STATE OF WISCONSIN HFS 107.13(2), Wis. Admin. Code

FORWARDHEALTH

PERSONAL CARE ADDENDUM
Instructions: Print or type clearly. Refer to the Personal Care Addendum Completion Instructions, F-11136A, for information on completing this form. SECTION I -- PROVIDER INFORMATION 1. Name -- Provider 2. Provider Number

SECTION II -- MEMBER INFORMATION 3. Name -- Member 4. Member Identification Number

SECTION III -- GENERAL ASSESSMENT 5. Skilled Visits Required by Member (Check all that apply.) Registered Nurse Licensed Practical Nurse Home Health Aide 6. Communication Capability (Check one.) Communicates needs verbally. Communicates verbally with difficulty, but can be understood. Communicates with sign language, symbol board, written messages, gestures, or interpreter. Communicates inappropriate content, makes garbled sounds. Does not communicate needs. Child with age-appropriate communication. 7. Hearing Aid Usage Does the member wear a hearing aid? Yes No Physical Therapist Occupational Therapist Speech-Language Pathologist

If yes, what is the member's ability to hear with the hearing aid, if customarily worn? (Check one, if applicable.) No hearing impairment. Hearing difficulty at level of conversation. Hears and understands only very loud sounds (e.g., person speaking to member must yell to be heard.) No useful hearing; unable to interpret audible sounds. Not determined. 8. Vision Correction Does the member wear corrective lenses? Yes No

If yes, what is the member's ability to see with corrective lenses, if customarily worn? (Check one, if applicable.) Has no impairment of vision. Has difficulty seeing at level of print, but may be able to read large or thick print. Has difficulty seeing obstacles in environment. Has no useful vision. Not determined. Continued

PERSONAL CARE ADDENDUM F-11136 (10/08)

Page 2 of 4

SECTION III -- GENERAL ASSESSMENT (Continued) 9. Orientation (Check one.) Oriented Minor forgetfulness of the following (Check all that apply.) Time Place Person Partial or intermittent periods of disorientation in the following (Check all that apply.) a.m. p.m. Two Hours or Less Totally disoriented -- does not know time, place, or identity Comatose Not determined 10. Medications Medication Name Dosage / Frequency Route Start Date End Date Consistently Inconsistently Medications Meals

11.

Supporting Rationale for Requested Increase of Units

Continued

PERSONAL CARE ADDENDUM F-11136 (10/08)

Page 3 of 4

SECTION IV -- SOCIAL INFORMATION 12. Social / Economic / Cultural Factors

13.

Scheduled Activities Outside Residence Does the member attend regularly scheduled activities outside his or her residence? If yes, specify in the following table the times of day for each activity. Yes No

Scheduled Activity School Work Day Program Other (Specify) _______________ Other (Specify) _______________

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

SECTION V -- HISTORY OF CONDITION 14. Condition / Past and Present Problems Affecting Personal Care

Continued

PERSONAL CARE ADDENDUM F-11136 (10/08)

Page 4 of 4

SECTION VI -- STAFFING SCHEDULE 15. Staffing Schedule of Each Agency or Provider Providing Services Specify the times of day each provider provides services. Level of Care Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Skilled Nursing Services

Home Health Aide Services

Personal Care Worker Services

Case Sharing (Specify agency[ies]) _________________

Other (Specify, e.g., Home and Community-Based Waiver Services Worker) _________________ 16. Other Information

SECTION VII -- SIGNATURE 17. SIGNATURE -- Authorized Nurse Completing Form 18. Date Signed

Reset Form