Help with Forms

Common forms that are brought in by our patient include:

·         M11Q form, (re) application for home care services – see below

·         Disability assessment forms –see below

·         Health exam forms for school/work/shelter/other doctors – these generally request a recent exam, immunization record or lab serology, PPD records. Occasionally some agencies will ask for an carefully done urine toxicology test (check with your PIC about what this means) .

·         Transportation forms MAT2015 – These forms are completed for patients who have difficulty ambulating to clinic or using public transportation. We now have a social worker on staff to complete these. Your job is to agree or disagree with the need of medical transportation.

·         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

·         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 assure 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. 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, but can remind patients to take their meds).  Although many pts would like to have home care services remember that this service should only be ordered for patients who are truly in need of personal care services due to comorbid disease and impairment in at least one ADL.

Physicians will be only asked to provide past medical hx and functional assessment on the form, you do not recommend hours of service as that is determined by the HRA agency with a home inspection.  This form needs to be recertified and completed twice a year for all patients receiving ongoing home services. The patient must be examined within 30 days of the recertification date. 


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 an initial home assessment visit.  


2 The NY State Office of Temporary and Disability Assistance-Disability Determination Form (click on link for info)

3  Medicaid Transportation form 2015-  You will need to sign to agree or disagree with the indication for medical transportation. We have a social worker now on staff to help complete and fax the forms to the NYP txp office  746 8260.

2. 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, PO Box 4602, Rensselaer, N. Y. 12144-4602). When completing the form for pts who have runned out of Rx benefits, ask the staff to make a copy for the pt before mailing, so the pt can bring it to the pharmacy to obtain further refills.