Fillable PRIOR APPROVAL UTILIZATION REVIEW ON-SITE REVIEW (North Carolina)

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PRIOR APPROVAL UTILIZATION REVIEW ON-SITE REVIEW (North Carolina)

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Adult Care Home FL2 Form
PRIOR APPROVAL UTILIZATION REVIEW ON-SITE REVIEW
IDENTIFICATION
1. PATIENT’S LAST NAME FIRST MIDDLE 2. BIRTHDATE (M/D/Y) 3. SEX
4. ADMISSION DATE (CURRENT LOCATION)
5. COUNTY AND MEDICAID NUMBER
6. FACILITY ADDRESS
7. PROVIDER NUMBER
8. ATTENDING PHYSICIAN NAME AND ADDRESS
9. RELATIVE NAME AND ADDRESS
10. CURRENT LEVEL OF CARE
HOME
SNF
ICF
HOSPITAL
DOMICILIARY (REST HOME)
OTHER
HOME
SNF
ICF
HOSPITAL
DOMICILIARY (REST HOME)
OTHER
12. PRIOR APPROVAL NO.
14. DISCHARGE PLAN
HOME
SNF
ICF
HOSPITAL
DOMICILIARY (REST HOME)
OTHER
13. DATE APPROVED/DENIED
15. ADMITTING DIAGNOSES – PRIMARY, SECONDARY, DATES OF ONSET
1.
5.
2.
6.
3.
7.
4.
8.
16. PATIENT INFORMATION
DISORIENTED
AMBULATORY STATUS
BLADDER
BOWEL
CONSTANTLY
AMBULATORY
CONTINENT
CONTINENT
INTERMITTENTLY
SEMI-AMBULATORY
INCONTINENT
INCONTINENT
INAPPROPRIATE BEHAVIOR
NON-AMBULATORY
INDWELLING CATHETER
COLOSCOPY
WANDERER
FUNCTIONAL LIMITATIONS
EXTERNAL CATHETER
RESPIRATION
VERBALLY ABUSIVE
SIGHT
COMMUNICATION OF NEEDS
NORMAL
INJURIOUS TO SELF
HEARING
VERBALLY
TRACHEOSTOMY
INJURIOUS TO OTHERS
SPEECH
NON-VERBALLY
OTHER
INJURIOUS TO PROPERTY
CONTRACTURES
DOES NOT COMMUNICATE
02 PRN CONT
OTHER:
ACTIVITIES/SOCIAL
SKIN
NUTRITION STATUS
PERSONAL CARE ASSISTANCE
PASSIVE
NORMAL
DIET
BATHING
ACTIVE
OTHER:
SUPPLEMENTAL
FEEDING
GROUP PARTICIPATION
DECUBITI-DESCRIBE:
SPOON
DRESSING
RE-SOCIALIZATION
DRESSINGS:
PARENTERAL
TOTAL CARE
FAMILY SUPPORTIVE
NASOGASTRIC
PHYSICIAN VISITS
NEUROLOGICAL
GASTROSTOMY
30 DAYS
CONVULSIONS/SEIZURES
INTAKE AND OUTPUT
60 DAYS
GRAND MAL
FORCE FLUIDS
OVER 180 DAYS
PETIT MAL
WEIGHT
FREQUENCY
HEIGHT
17. SPECIAL CARE FACTORS
FREQUENCY
SPECIAL CARE FACTORS
FREQUENCY
BLOOD PRESSURE
BOWEL AND BLADDER PROGRAM
DIABETIC URINE TESTING
RESTORATIVE FEEDING PROGRAM
PT (BY LICENSED PT)
SPEECH THERAPY
RANGE OF MOTION EXERCISES
RESTRAINTS
18. MEDICATIONS/NAME & STRENGTH, DOSAGE & ROUTE
1.
7.
2.
8.
3.
9.
4.
10.
5.
11.
6.
12.
19. X-RAY AND LABORATORY FINDINGS/DATE:
20: ADDITIONAL INFORMATION
9.2018
21. PHYSICIAN’S SIGNATURE
DATE
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PRIOR APPROVAL UTILIZATION REVIEW ON-SITE REVIEW (North Carolina)

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Completed 13 December 2021

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