1. health and fitness
2. therapy

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Sample Packet for a primary diagnosis of Autism.
Level of Care: ICF/MR (Intermediate Care Facility/Mental Retardation)
Your packet should contain:
1.
2.
3.
4.
A cover letter outlining what's in your packet and a picture of your child.
Financial Summary (Medicaid Form 94 – you may have done this online)
Copies of last 2 check stubs and bank statements
DMA 285 – Insurance Form and copy of insurance card
And the Medical side of it – with forms signed by the doctor
5. DMA 6A (Crazy Box Form)
6. DMA 6A Attachment 1: Medical History
7. DMA 6A Attachment 2: Prescription list (includes dosage and frequency)
8. Other attachments that won't fit in the boxes on the forms (diagnoses, treatments, etc.)
9. DMA 706 Letter of Medical Necessity and Care Plan
10. DMA 704 Cost Effectiveness Form
11. Copy of latest psychological exam or developmental pediatrician report. Clearly mark (place a
sticky note to the side) where test results point to below average in Adaptive (Self Care, Self
Direction, Age Appropriate Ability to Live), Communication, Motor/Mobility scores. You need
to have scores 2 standard deviations below the norm in 3 of these areas.
12. Copy of latest IEP. Clearly mark (place a sticky note to the side) where services outline the
number of therapeutic sessions your child receives in the span of a week (how much SLP, OT,
PT, Behavioral Support/Social Skills training). Combined with your private therapies, this total
number of therapies should equal 5.
13. Copy of reports that verify diagnosis.
14. Copies of medical records – if this is your first time, throw in EVERYTHING you can find. If
this is a subsequent year, include just last year's records.
If this has been helpful, please consider making a donation to Southside Suport, Incorporated so we can
continue to keep forms updated on the website. Www.southsidesupport.org. Southside Support, P. O.
Box 812, Fayetteville, GA 30214. Email: [email protected]
Last Modified: 10-29-12
Type of Program:
PEDIATRIC DMA 6(A)
Nursing Facility
GAPP
TEFRA/Katie Beckett
PHYSICIAN’S RECOMMENDATION FOR PEDIATRIC CARE
Section A – Identifying Information
1. Applicant’s Name/Address:
2. Medicaid Number:
Your Childs Name
Name: _____________________________________
initial
application
____________________________
3. Social Security Number
1233 Four Street
Address: ___________________________________
333-33-3333
4. Sex
Age
M/F
4A. Birthdate
under 18
01-01-01
Cityville GA 30000
__________________________________________
Dr. Doctor
5. Primary Care Physician: _______________________________________________
Fayette
DFCS County: ______________________________
770-000-0001
6. Applicant’s Telephone # _______________________________________________
7. Does guardian think the applicant should be institutionalized?
Yes
8. Does child attend school?
Yes
No
No
Mom the Awesome
Name of Caregiver #1: ____________________________________
9. Date of Medicaid Application
12
01
12
_______/______/______
Dad the Fantastic
Name of Caregiver #2: _______________________________________
I hereby authorize the physician, facility or other health care provider named herein to disclose protected health information and release the
medical records of the applicant/beneficiary to the Georgia Department of Community Health and the Department of Human Services, as
may be requested by those agencies, for the purpose of Medicaid eligibility determination. This authorization expires twelve (12) months
from the date signed or when revoked by me, whichever comes first.
10. Signature: ____________________________________________________
(Parent or other Legal Representative)
12 01 12
11. Date: _____/_____/____
Section B – Physician’s Report and Recommendation
12. History: (attach additional sheet if needed)
see attached sheet
13. Diagnosis
Autism
1) _________________________
2) __________________________ 3) _________________________
(Add attachment for additional diagnoses)
14. Medications 1. ICD
2. ICD
3. ICD
299.0
15. Diagnostic and Treatment Procedures
Name
Zoloft
Dosage
10 ml
oral
Route Frequency
1 per day
Type
Frequency
SLP
2X/Week
OT
1X/week
Behavior Therapy
5X/week
16. Treatment Plan (Attach copy of order sheet if more convenient or other pertinent documents)
1-01-01
Previous Hospitalizations: ___________________
Rehabilitative Services: _____________________ Other Health Services: ________________
Premature birth
Hospital Diagnosis: 1) __________________________
2) Secondary ____________________________ 3) Other _______________________
None
17. Anticipated Dates of Hospitalization: ________________
18. Level of Care Recommended:
Hospital
Nursing Facility
■
IC/MR Facility
19. Type of Recommendation: 20. Patient Transferred from (check one): 21. Length of Time Care Needed ____ Months 22. Is patient free
■ Initial
Hospital
Another NF
1) ✔ Permanent
of communicable
Change Level of Care
Private Pay
Lives at home 2) Temporary________estimated
diseases?
Continued Placement
Yes
No
23. This patient’s condition
✔
could
could not be managed by provision of
Community Care or
Home Health Services
Dr. Doctor
24. Physician’s Name (Print): _____________________________________________________________________________
1445 Big Hospital Lane, Cityville, GA 30000
Physician’s Address (Print): ___________________________________________________________________________
25. I certify that this patient requires the level of care provided by a nursing facility, IC/MR facility, or hospital
______________________________________________________________________ Physician’s Signature
12 01 12
26. Date signed by Physician _____/_____/____
222222
27. Physician’s Licensure No. _________________________________
770-000-0002
28. Physician’s Telephone #: _________________________________
Page 1 of 2
Section C– Evaluation of Nursing Care Needed (check appropriate box only)
29. Nutrition
30. Bowel
31. Cardiopulmonary Status 32. Mobility
33. Behavioral S tatus
Regular
Age Dependent
Monitoring
Prosthesis
Agitated
Diabetic Shots Incontinence
CPAP/Bi-PAP
Splints
Cooperative
Formula-Special
Incontinent - Age > 3 years
CP Monitor
Unable to ambulate >
Alert
Tube feeding
Colostomy
Pulse Ox
18 months old
Developmental Delay
N/G-tube/G-tube
Continent
Vital signs > 2/days
Wheel chair
Mental Retardation
Slow Feeder
Other ______________
Therapy
Normal
Behavioral Problems
FTT or PrematureFrequent accidents
Hyperal
Oxygen
IV Use
Trach
Medications/GT
Nebulizer Tx
Meds
Suctioning
Special Diet -
Chest - Physical Tx
GFCF
Room Air
34. Integument System
(please describe, if checked)
Uses inserts for
Home Ventankle pronation
35. Urogenital
36. Surgery
Suicidal
Hostile
Autism - aggression and
outbursts (tantrums),
elopement
37. Therapy/Visits
38. Neurological Status
Burn Care
Dialysis in home
Level 1 (5 or > surgeries) Day care Services
Deaf
Sterile Dressings
Ostomy
Level II (< 5 surgeries)
High Tech - 4 or more
Blind
Decubiti
Incontinent – Age > 3 years
None
times per week
Seizures
Bedridden
Catheterization
Low Tech – 3 or less
Neurological Deficits
Eczema-severe
Continent
times per week or MD
Paralysis
visits > 4 per month
Normal
Normal
Frequent accidents
Frequent
eczema
39. Other Therapy Visits
■
Five days per week
None
40. Remarks
Less than 5 days per week
N/A
41. Pre-Admission Certification Number: __________________________________
12
01 12
42.Date Signed _____/____/____
Dr. Doctor
43. Print Name of MD or RN: ___________________________________________________________
Signature of MD or RN: ______________________________________________________________
DO NOT WRITE BELOW THIS LINE
44. Continued Stay Review Date: ____________ Admission Date: _____________ Approved for _________ Days or ___________ Months
45. Are nursing services, rehabilitative services or other health related services requested ordinarily provided in an institution? Yes
No
46A. State Authority MH & MR Screening
Level I/II
Restricted Auth. Code
Date
46B. This is not a re-admission for OBRA purposes
47. Hospitalization Precertification
Restricted Auth. Code
Met
Not Met
48. Level of Care Recommended by Contractor
Hospital
Nursing Facility
49. Approval Period
50. Signature (Contractor)
51. Date ________________________________
_____/____/____
Page 2 of 2
Date
IC/MR Facility
52. Attachments (Contractor)
Yes
No
DMA-6A (11/2011)
TEFRA/Katie Beckett Medical Necessity/Level of Care Statement
Your Child's Name
01-01-01
333-33-3333
Member Name:_________________________
DOB: _______
SS#_______________
Autism
299.0
Diagnosis: ________________________________________________________________________________
_________________________________________________________________________________________
Recommended level of Care:
✔
Nursing facility level of care
Hospital level of care
Level of care required in an Intermediate Care Facility for MR (ICF-MR)
Medical History: (May attach hospital discharge summary or provide narrative):
See attached medical history (attached history should include prenatal history, early childhood development, and major surgeries and diagnoses. You can also
__________________________________________________________________________________________
include dates of hospitalization, severe illnesses, or even a range of dates when chronic infections took place: 5 ear infections winter 2004
__________________________________________________________________________________________
____________________________________
Current Needs
Cardiovascular:
Neurological:
Respiratory:
Nutrition:
Integumentary:
Urogenital:
Bowel:
Endocrine :
Immune:
Skeletal:
Other:
None
____
____
____
____
____
____
____
____
____
____
____
Description of Skilled Nursing Needs
__________________________________________
Yearly EEG as needed for seizure review
__________________________________________
Nebulizer for allergy attacks
__________________________________________
GFCF Diet and supplementation
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
Behavioral therapy 5X weekly with ABA at school
__________________________________________
3
0
2
Therapy: Speech sessions/wk ____
PT sessions/wk ____
OT sessions/wk ____
(attach current notes)
Hospitalizations within last 12 months: (Attach most recent hospital discharge summary)
Date: _________ Reason: __________ Duration: __________________________
SLP and OT sessions done through school system - refer to IEP for goals and progress. No hospitalizations
Comments: ______________________________________________________________
in past year. Last surgery 12/2006 for removal of adenoids/tonsils
________________________________________________________________________
YES
6
5
X (attach if in effect)
Child in school: _____
Hrs per day _____
Days per wk ___
N/A ____ IEP/IFSP __
X
Nurse in attendance during school day: _____ N/A ____(attach
last month’s nursing notes)
X
Skilled Nursing hours received: Hrs./day ______ N/A ________
I attest that the above information is accurate and this member meets Pediatric Level of Care Criteria and
requires the skilled care that is ordinarily provided in a nursing facility, hospital or facililty whose primary
purpose is to furnish health and rehabilitative services to persons with mental retardation or related conditions.
Physician’s Signature:
__________________________
Primary Caregiver Signature: __________________________
12-01-12
Date: ____________
12-01-12
Date: ____________
** Foster Care Applicants must have the signature of the DFCS representative.
DMA – 706
Rev. 04/11
TEFRA/Katie Beckett
Cost-Effectiveness Form
(Child’s physician must complete Form)
The following information is requested for the purpose of determining your patient’s eligibility for
Medicaid:
Patient’s Name:______Your Child’s Name______ Medicaid #:____Initial Application _______
Diagnosis:____Autism 299.0 ______________________________________________________
Prognosis:_______fair___________________________________________________________
Please provide the estimated monthly costs of Medicaid services your patient will need or is seeking for
Medicaid to cover for in-home care:






Physician’s services
Durable medical equipment
Drugs
Therapy(s)
Skilled Nursing Services
Other(s)__behavior therapy____
$___200_________
_______________
____90 (co-pay amount)_
____800________
_______________
_____400_______
TOTAL
$____1400_______
Will home care be as good or better than institutional care?
_____X_____ Yes
__________ No
COMMENTS:
Note, my child has primary insurance through his parents. It picks up a substantial portion of
monthly costs. We anticipate Medicaid paying for co-pays, medication, deductible, and some dental
and vision services only.
PHYSICIAN’S SIGNATURE _______________________________________________________
DATE: ______________12-01-12_____________________________________________
DMA Form 704
Rev. 10-04