Help with Forms

Common forms that are brought in by our patient include:

·         Health exam forms for school/work/shelter/other doctors

·         Transportation forms MAT2015

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

·         Medicaid Override Forms to increase service need

·         Dental Pre-procedure evaluation form

·         VNS orders for signatures

·         disability assessment forms

·         Housing Applications

These forms sometimes may 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 Override Form – this is needed when your patient exceed the standard Medicaid benefits for doctor visits or prescriptions.

2. Medicaid Transportation form MAP 2015- for patients who have mobility problems and are unable to take public transportations. This form is available in each modules or can be printed here. After signing the form, please direct the patient to our floor SW and they will help complete the rest of the information, and fax it into the- (transportation office 746-8260  ). Once the form is received, the pt then can access the Columbia Dispatch Service at 746-4000. This service can also be activated on the day of the patient’s appt with you.

** Medicaid Manage Care (Affinity, NYP Community Plan, etc) do not use the MAP form. In order to get approval for transportation one must write a brief letter noting patient’s medical condition and reason for need of transportation (i.e. poor mobility due to…). Be sure to include patient’s Medicaid Number on letter, then fax the letter to the plans.

For NYP Community Plan use fax 212-297-5998.

3. The NY State Office of Temporary and Disability Assistance-Disability Determination Form

3.  VNS Plan of Care Form (PDF) (see VNS section also) This form enables you to order VNS home visits, Home Health Aide service, PT, Social Work services.... 

3. M11Q form is a form from the City of New York 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- see flyer for info on home care.

 

The form is a little more involved (4 pages), and needs to be completed once a year for all patients receiving home services. 

 

step 1background info- The most important part is the past medical history (page1) and a brief assessment from you of the patients limitation (page2).  Be sure to list all diagnosis that will contribute to functional need.

step 2 patient's needs-Fill out the bottom of page 3 only if you are sure that the patient needs the services that you can check off. If you are unsure what the patient's needs are, or are unsure whether they even qualify for the home service, do not check anything off.   Write on the narrative page 4 for "would defer to your assessment".

step 3 signature/contact info/date: make sure this part (bottom of page 3) is completed or else the forms will not be accepted by CASA. 

 

Once the form is completed, you can either give it to one of the clinic social workers or mail it in to CASA for intake/approval.  Usually patients will be contacted by CASA within one week 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.

Main CASA Mailing address

HCSP

309 E. 94 St.

NY, NY 10128-5683                          See website for other CASA addresses