Assistive Care Services and Assisted Living for the Elderly Waiver

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CERTIFICATION OF MEDICAL NECESSITY FOR MEDICAID ASSISTIVE CARE SERVICES Optional Form Patient Name ________________________________________ DOB _____________ This is to certify that this patient is in need of an integrated set of assistive care services on a 24-hour basis, including at least two of the following four service components (check as applicable): ____ Assistance with activities of daily living, which is defined as individual assistance with ambulating, transferring, bathing, dressing, eating, grooming, and/or toileting. ____ Assistance with instrumental activities of daily living, which is defined as individual assistance with shopping for personal items, making telephone calls, managing money, etc. ____ Health support, which is defined as observing the resident’s whereabouts and wellbeing; reminding the resident of any important tasks; and recording and reporting any significant changes in appearance, behavior, or state of health to the health care provider, designated representative, or case manager. ____ Assistance with self-administration of medication, which is defined as assistance with or supervision of self-administration of medication as permitted by law. HEALTH CARE PROVIDER (Not an employee of the ACS facility): Typed Name License Number Signature Date Signed ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ RETURN TO: Facility Name & Address Contact Person & Phone # ____________________________________________________ ____________________________________________________ (AHCA Form 5000-3100B July 2001)
Assistive Care Services and Assisted Living for the Elderly Waiver Services Coverage and Limitations Handbook PART I APPENDIX D ASSISTIVE CARE SERVICES SERVICE PLAN FORM INSTRUCTIONS The following pages contain an optional service plan form for assistive care services. The form may be copied and used by providers to document the service plan. ACTIVITIES General Information The activities on this form match those listed on the DOEA Health Assessment Form and the service components on the Medical Necessity Certification. If the individual does not need any help with an activity, check "Independent." SERVICE The level of service to be provided (supervision, assistance, total help, etc.) should match the need shown on the Health Assessment7. • If the individual is independent in an activity, no other information need be provided for that activity. • Providing supervision generally means reminding the individual to perform the activity, cueing the individual as to how to do the activity, and monitoring that the individual completes the activity. • Providing assistance includes the tasks specified below under each activity on a daily basis. • Providing total help means that the provider performs the entire activity for the resident because the resident is unable to perform any part of the activity for himself/herself. PROVIDER Show who will be responsible for providing the service needed. If the provider is other than Facility Staff, specify who will be responsible, for example, daughter or home health agency. EXPECTED OUTCOME Specify how the resident is expected to function when the proper amount and type of care is provided; the purpose of the service. OTHER Specify any other information about the service to be provided. July 2001 D-1
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Assistive Care Services and Assisted Living for the Elderly Waiver

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