Help with Forms
Common forms that are brought in by our patient include:
· Health exam forms for school/work/shelter/other doctors – need to have immunization record or serology, and sometimes PPD to complete these.
· Transportation forms MAT2015 – we now have a social worker on staff to complete these. See below
· M11Q form, (re) application for home care services – see below
· Medicaid Override Forms to increase service need-see below
· Dental Pre-procedure evaluation form – just state pt’s Pmhx and need for peri procedure abx or a/c therapy
· Disability assessment forms –see below
· Housing Applications Form – to get priority housing, a MD need to certify that the housing problem is a direct threat to health.
These forms often contribute to time management problems while you are seeing patients. Depending on the complexity of the information requested and how busy you are, one approach is to reassure the patient that you will be happy to fill their form after you finish seeing all your patients. Patients can leave you their mailing address or return to pick up the completed form from your secretaries later.
1. What is the Medicaid
Utilization Threshold Program and the Override Application form – this form
is needed when your patient exceed the standard Medicaid benefits for doctor
visits or prescriptions. Ask your PIC for instructions on how to fill these
out. Each module should have a blank form available. The provider code for MD
service is 0460. Be sure to write neatly or else it will be rejected. Once the
form is completed ask your staff to mail out to Medicaid CSC (Computer Sciences Corporation,
3. The NY State Office of
Temporary and Disability Assistance-Disability Determination Form
2. Medicaid
Transportation form MAP 2015- We
have a full time social worker now on staff to deal with these forms. They will
complete, obtain signatures (from you or a covering attd),
and fax to NYP office 746 8260
3. M11Q form is a form from the City of New York Home Care Service Program that directs authorization for Home Attendant Services. A home attendant is someone who can assist with chore service and personal care (they have no health care training and can not administer medicine). Although most of us would all like to have our shopping and laundry done by someone, we must remember that this service should only be ordered for patients who are truly in need of personal care services.
The form needs to be completed once a year (recertification) for all patients receiving and needing ongoing home services. There is now a requirement for signature by only licensed NY MDs (interns please ask your Firm chief to cosign). For further instructions.
Once
the form is completed, you can either mail it back with the attached envelope
for recerts, or give it to one of the clinic social
workers to help initiate new services (you can also mail directly to
CASA). Usually patients will be contacted by CASA in a few weeks to
schedule a home assessment visit. A
decision on whether they will receive services is usually made within a month.
Click here for more info on the M11Q or a list of CASA mailing addresses.
Most
nearby CASA office is
|
CASA V 5th Floor
(Community Districts 9-12)
Phone: (212) 665-4729 Fax: (212) 666-1459 |