QMRP CERTIFICATION FOR ICF/MR LEVEL OF CARE WAIVER
State Form 51036 (10-02) / OMPP 450B/QMRP Indiana Family and Social Services Administration (IFSSA)
ASSESSMENT TYPE Initial Assessment Re-Screening
MEDICAID STATUS Medicaid Pending Medicaid Recipient
Name of contact:
Upon completion return to: I - RECIPIENT IDENTIFICATION
Bureau of Developmental Disability Services Name of applicant: (last, first, middle) Date of birth: (mo., day, yr.) Name of county:
Name of nursing facility or ICF / MR (if applicable):
Address: (street and number)
City, state and zip code:
II - MEDICAL SUMMARY Fedral and state regulations require a physician's physical examination*, plan of treatment and recommendations for care prior to admission or continued care in the Medicaid Home and Community-Based Waiver program. Check all applicable boxes below and attach current (within past year) medical documentation (Physician's medical records, hospital discharge summary, facility chart records, etc.) to support each item checked. Ambulatory Wheelchair Cane or Walker Bedfast Ventilator Dependant Contractures Incontinent (bladder) Incontinent (bowell) Catheter Tracheotomy Colostomy / Ileostomy Other Ostomy Aphasic Agitated / Combative Confused / Disoriented Self Fed I.V. Fluids / Nutrition Tube Fed - Type Decubiti (size, stage, treatment) Other
Primary diagnosis (include dates)
Secondary / tetiary diagnosis (include dates)
ATTACH copy of current (within past year) PHYSICAL EXAMINATION by physician (MD or DO) may also attach Form 450B - Section VI "Physician Examination".
List medications: (attach documentation verifying medications, dosage and frequency)
QMRP LEVEL OF CARE RECOMMENDATION / COMMUNITY CERTIFICATION Level of care recommended:
Medicaid Home and Community Based Waiver service I certify that community supported in-home care is safe and feasible ICF/MR - Level of Care Other: not safe or feasible in regard to health and safety of this patient. If not safe or feasible, explain.
Signature of QMRP (stamps are NOT acceptable)
Date signed (month, day, year)
Typed or printed name of QMRP
This certification is for: Initial Approved Authorized signature
III - LEVEL OF CARE AUTHORIZATION Comments
Update Disapproved OMPP Area agency Other QMRP Date signed (month, day, year) Annual Effective Medicaid reimbursement date
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). 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 willl be treated as confidential pursuant to Regulation 470 IAC 1-3-1.