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State Form 38143 (R5 / 6-93) Form 450B / PASARR2A Indiana Family and Social Services Administration (IFSSA)


ASSESSMENT TYPE Initial Assessment Re-Screening ARR

MEDICAID STATUS Medicaid Pending Medicaid Recipient Non-Medicaid IFSSA Other ________________

Name of contact

Area PAS agency Integrated Field Services Case Manager I - RECIPIENT IDENTIFICATION
Date of birth (mo., day, yr.) Sex

Upon completion return to:

Name of applicant (last, first, middle) Name of nursing facility or ICF / MR

Name of county

Facility admission date (mo., day, yr.) Re-admission date from hospital

Medicaid number

Address of facility (street and number) City, state and ZIP code

Level of care transfer date

Requested length of care

Facility provider number(s)

Admitted from:


"I". "S".


f. Out-of-state _______________________________

a. Acute Hospital b. Psychiatric Bed

d. Nursing Facility ________________________________________________ e. ICF/MR g. Other ____________________________________ II - PHYSICIAN'S MEDICAL EVALUATION

Federal and state regulations require a physician's medical evaluation, plan of treatment and explicit recommendation for care prior to admission or continued care in a nursing facility, the C.H.O.I.C.E. program, or the Medicaid Home and Community-Based Waiver program.
Patient Evaluation (check all applicable boxes below. Ambulatory Wheelchair Cane or Walker Bedfast Ventilator Dependent
Primary diagnosis (include dates)

"*" requires explanation in "Clinical Summary")
Colostomy / Ileostomy Other Ostomy Aphasic Agitated / Combative Confused / Disoriented Self Fed I.V. Fluids / Nutrition * Tube Fed - Type _____________ Decubiti (size, stage, treatment) * Other *______________________

Contractures Incontinent (bladder) Incontinent (bowel) Catheter _________________ Tracheotomy

Secondary / tertiary diagnosis (include dates)

Patient's overall prognosis

Plan and Treatment (check all applicable boxes below. Medications (describe below) Restorative Services * Sterile Dressing *
Medications (dosage and frequency) Clinical summary (attach additional information as necessary)

"*" requires explanation in "Clinical Summary")
Minimum Nursing Intervention Moderate Nursing Intervention * Intensive Nursing Intervention * Independent with ADLs Assisted with ADLs Dependent for all ADLs

Regular Diet Other (specify _______________ ___________________________

Level of care recommended

ICF/MR - Large/Small

LEVEL OF CARE PHYSICIAN CERTIFICATION Complete for all Applications Complete for Home Care (if applicable) Skilled Intermediate Medicaid Home and Community Based Waiver service Other (specify) __________________________ C.H.O.I.C.E. safe and feasible not safe or feasible in regard to health and safety of this patient. If not safe or

I certify that community supported in-home care is feasible, explain.
Signature of physician (stamps are NOT acceptable)

Date signed (month, day, year)

Typed or printed name of physician

This certification is for: Comments

Admission Approved
Authorized signature

Transfer Disapproved

Continued Care
Effective Medicaid reimbursement date

Area PAS agency

Date signed (month, day, year)

INSTRUCTIONS Physician's Certification for Long-Term Care Services 1. Form 450B is used for both Medicaid and private-pay applicants for long-term care services and C.H.O.I.C.E. eligibility. Do not use for non-Medicaid/private pay individuals being readmitted from hospitalizations or being transferred to another facility. 2. Form 450B shall be completed for persons making application for long-term care services. 3. The recipient's or patient's physician shall complete Section II, PHYSICIAN'S MEDICAL EVALUATION, including the patient's evaluation, plan of treatment, specify a level of care, sign, date and return the original to the appropriate agency as designated below. Pre-Admission Screening . . . . . . . . . . . . . . Local PAS Agency C.H.O.I.C.E. . . . . . . . . . . . . . . . . . . . . . . . . Local Area Agency on Aging ICF / MR . . . . . . . . . . . . . . . . . . . . . . . . . . . Integrated Field Services Case Manager Facility Transfers State Office of Medicaid Policy and Planning Medicaid Waiver Application. . . . . . . . . . . . . Local Area Agency on Aging ....... Medicaid Waiver Redetermination . . . . . . . . Waiver Case Manager .... ....... 4. Form 450B will be sent to the State Office of Medicaid Policy and Planning for final review and determination. For C.H.O.I.C.E. applicants / clients and private pay applicants for long-term care, Form 450B will be sent to the Area Agency on Aging for final review and determination. 5. The decision on admission, as well as the level of care (as applicable), will be entered in Section III and will be sent to the County Division of Family and Children, to the nursing facility and the PAS agency as appropriate. 6. For ICF / MR applicants, Section VI must also be completed and submitted for level of care determinations. For PAS ARR/ MR applicants / residents requiring a Level II assessment, Section VI must also be completed and submitted for level of care determinations. Appeal Rights / How to Request an Appeal If you are not satisified with this decision, you may request an appeal within 30 days of the date of receipt of this decision. Send a letter with your signature to the Indiana Family and Social Services Administration, Division of Family and Children, Hearings and Appeals, 402 W. Washington St., Rm. W392, Indianapolis, Indiana 46204. (470 IAC 1-4 et. seq.) Be sure that the letter contains your address and a telephone number where you can be reached. It is also helpful if you attach a copy of this decision or state the nature of the action you are appealing. If you are unable to write this letter yourself, you may have someone assist you in requesting this appeal. You will be notified in writing by the Division of Family and Children of the date, time and place for the hearing. Prior to, or at the hearing, you will have the right to examine the entire contents of your case record. You may represent yourself at the hearing or authorize a representative such as an attorney or other spokesperson to do so. At the hearing you will have full opportunity to bring witnesses, establish all pertinent facts and circumstances, advance any arguments without interference and question or refute any testimony or evidence presented. C.H.O.I.C.E. PROGRAM APPLICANTS / CLIENTS: If you are not satisified with the decision on your C.H.O.I.C.E. case, you should discuss this matter with staff at your Local Area Agency on Aging. DISCLOSURE STATEMENT The personal information requested on this form will be used in the determination of your entitlement to or continued receipt of public assistance and/or services administered by the State of Indiana. Disclosure of the information requested is mandatory pursuant to the provision of IC 12-15-2 et. seq. (Medicaid Programs); IC 12-10-10 et. seq. (C.H.O.I.C.E. Program); and IC 12-21 (Division of Mental Health). Non-disclosure of the information requested will hamper and possibly prevent the delivery of assistance or services to you. All personal information collected on this form will be treated as confidential pursuant to Regulation 470 IAC 1-3-1.