- 3 -
PHYSICIAN’S ORDER FOR PERSONAL CARE/CONSUMER DIRECTED PERSONAL ASSISTANCE SERVICES
COMPLETE ALL ITEMS. (Attach additional sheets, if necessary). INCOMPLETE FORMS WILL BE RETURNED TO THE PHYSICIAN.
INCOMPLETE OR MISSING INFORMATION MAY DELAY SERVICES TO THIS PATIENT.
1. Patient Identifying Information
• Patient Name. Enter the patient’s name.
• CIN. Found on the patient’s Medical Assistance ID card.
• Date of Birth. Enter the patient’s date of birth.
• Sex. Enter the patient’s gender.
• Address and telephone number. Enter the patient’s address and telephone number.
• Medicare #. Enter the patient’s Medicare number if available.
• If currently hospitalized. If the patient is hospitalized at the time of completion of the physician's order, indicate the name of the
hospital, date of admission, and anticipated date of discharge.
• Discharge to above address. If the patient is to be discharged to an address other than the address listed above please explain.
• General Information
Physician’s Name, License #, Address, Telephone. Enter information for the physician signing the order. Enter either the physician’s
license number as issued by the New York State Department of Education or the provider billing number issued by the New York State
Department of Health Medicaid Management Information System.
• Examination conducted by other than a physician. If patient was examined, and the order form completed by a physician’s
assistant, specialist’s assistant, or nurse practitioner, complete the required information.
• Place of Examination. Indicate the location (office, clinic, home, etc) of the examination of the patient.
• Date of Examination. Enter the date the patient was examined. This must be within 30 days of the date the physician signed the
3. Medical Findings
Note: Indicate N/A if an item does not apply to this patient or Unk if the requested information is unknown to the physician signing this
• Height, Weight. Enter the patient’s height and weight.
• Primary and Secondary Diagnosis. Enter the primary and secondary diagnosis with ICD-9-CM codes for the primary and
secondary conditions which result in the patient being evaluated for home care services.
• Describes the current condition. Describe the patient’s current medical/physical condition, including any relevant history.
• Stability. Check Yes if the patient’s condition is not expected to show marked deterioration or improvement. A stable medical
condition shall be defined as follows:
(a) the condition is not expected to exhibit sudden deterioration or improvement; and
(b) the condition does not require frequent medical or nursing judgment to determine changes in the patient's plan of care; and
(c) (1) the condition is such that a physically disabled individual is in need of routine supportive assistance and does not
need skilled professional care in the home; or
(2) the condition is such that a physically disabled or frail elderly individual does not need professional care but does
require assistance in the home to prevent a health or safety crisis from developing.
• Hospice. If the patient’s condition is terminal, indicate if the patient is appropriate for Hospice services.
• Describe the current treatment plan. Include therapeutic goals and prognosis for recovery and anticipated duration of the current
• Limitations. Indicate any functional limitations or prohibited activities.
• Self-Directing. Indicate if the patient is self-directing. Self-directing means that the patient is capable of making choices about
activities of daily living, understanding the impact of the choices, and assuming responsibility for the results of the choices. A No
response to this item should be reflected in the description of the patient’s condition as documented in the applicable section.
• Able to Summon Help. Check Yes if the patient is able to summon assistance in an emergency situation by any means. If the
patient is not able to summon assistance, check No and explain.