INSTRUCTIONS FOR COMPLETINGMA-51 MEDICAL EVALUATION NOTE: THE MA-51 IS VALID AS LONG AS IT REFLECTS THE CURRENT CONDITIONS FOR THE APPLICANT At the top of the page, mark if this is a new or updated MA-51. Questions 1-7 are self-explanatory. 8. þ Physician License Number. Enter the physician license number, not the Medical Assistance number. 10. þ Signature. Applicant should sign if able. If unable, legal guardian or responsible party may sign. 11. þ Essential Vital Signs. Self-explanatory. 13. þ Vacating of building. How much assistance does the patient require to vacate the building? 14. þ Medication Administration. Is the patient capable of being trained to self-administer medications? 18. þ Prognosis. Indicate patient222s prognosis based on current medical condition. 19. þ Rehabilitation Potential. Indicate based on current condition. Should be consistent with box 18. 20A. þ Physician222s Recommendation. Physician must recommend patient222s level of care. If the box for 223other224 is þ checked, write in level of care. In order to provide assistance to a physician in the level of care þ recommendation, the following definitional guidelines should be considered: 20B. þ Complete only if Consumer is NFCE and will be served in a Nursing Facility. Check whether the patient þ will be eventually discharged from facility based on current prognosis. If yes, check expected length þ of stay. 20C. þ The physician must sign and date the MA-51. A licensed physician must sign the MA-51. It may not be signed by a 223physician in training224 (a Medical Doctor in Training [MT] or an Osteopathic Doctor in Training [OT]).Questions 21 and 22 are completed by Aging Well or the appropriate Department of Human Services program office. These questions are used by the Department to certify the Individual222s medical eligibility for services. 16. þ Professional and Technical Care Needs. Indicate care needed. Examples of 223other224 include mental health þ and case management. 17. þ Physician Orders. Orders should meet needs indicated in box 16. Medications should have diagnoses to þ support their use. 9. þ Evaluation At. Enter 1-5 to describe where evaluation took place. If 5 is used, specify where evaluation was þ completed. 12. þ Medical Summary. Include any medical information you feel is important for determination of level of care. þ Please list patient222s known allergies in this section. 15. þ Diagnostic Codes and Diagnoses. ICD diagnostic codes should be put in the blocks, then written by þ name in the space next to the block. List diagnoses starting with primary, then secondary, and finally tertiary. þ There is room for any other pertinent diagnoses. Nursing FacilityClinically Eligible (NFCE)Personal Care HomeICF/ORC CareICF/ID CareInpatient Psychiatric Care Requires health-related care and services because the physical condition necessitates care and services that can be provided in the community with Home and Community Based Services or in a Nursing Facility. Provides Personal Care services such as meals, housekeeping, & ADL assistance as needed to residents who live on their own in a residential facility. Provides health-related care to ID individuals. More care than custodial care but less than in a NF. Provides health-related care to ORC individuals. More care than custodial care but less than in a NF. Provides inpatient psychiatric services for the diagnoses and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician. MA 51 3/19 American LegalNet, Inc. www.FormsWorkFlow.com MA 51 3/19 ORIGINAL TO þ CAO - RETAIN PHOTOCOPY FOR þ YOUR þ FILE MEDICAL EVALUATION NEW UPDATED 1. MA RECIPIENT NUMBER 11. HEIGHT 12. MEDICAL SUMMARY 13. IN EVENT OF AN EMERGENCY THE PATIENT CAN VACATE THE BUILDING 15. ICD DIAGNOSTIC CODES 16. PROFESSIONAL AND TECHNICAL CARE NEEDED - CHECK EACH CATEGORY THAT IS APPLICABLE 18. PROGNOSIS - CHECK ONLY ONE 20A þ PHYSICIAN222S þ RECOMMENDATION FOR DEPARTMENT USE To the best of my knowledge, the patient222s medical condition and related needs are essentially as indicated above. I recommend that theservices and care to meet these needs can be provided at the level of care indicated - check only one 20B. COMPLETE ONLY IF CONSUMER IS NURSING FACILITY CLINICALLY ELIGIBLE AND WILL BE SERVED IN A NURSING FACILITY. 20C. PHYSICIAN222S SIGNATURE 21 MEDICALLY ELIGIBLE 22 Comments. Attach a separate sheet if additional comments are necessary. 19. REHABILITATION POTENTIAL - CHECK ONLY ONE 17. PHYSICIAN ORDERS14. PATIENT IS CAPABLE OF ADMINISTERING HIS/HER OWN MEDICATIONS WEIGHT 1. Independently BLOOD PRESSURE TEMPERATURE PULSE RATE CARDIAC RHYTHM 7. ATTENDING PHYSICIAN 9. EVALUATION AT (Description and code) 10. þ For the purpose of determining my need for TITLE XIX INPATIENT CARE, Home and Community Based Services, and if applicable, my need for a shelter deduction, I authorize the release of any medical information by the physician to the county assistance office, Pennsylvania Department of Human Services or its agents. 01 þ Hospital02 þ NF03 þ Personal Care/Dom Care04 þ Own House/Apartment05 þ Other (Specify) 8. PHYSICIAN LICENSE NUMBER 2. NAME OF APPLICANT (Last, first, middle initial) 3. SOCIAL SECURITY NO. 5. AGE 6. SEX 4. BIRTHDATEDATESIGNATURE - APPLICANT OR PERSON ACTING FOR APPLICANT Physical Therapy Special Skin Care Medications Treatment Therapies Activities Social Services Special Procedures for Health and Safety or to Meet Objectives Diet Rehabilitative and Restorative Services Speech Therapy Parenteral Fluids Occupational Therapy Suctioning 1. Stable Nursing Facility Clinically EligibleServices to be provided at home orin a nursing facility ON THE BASIS OF PRESENT MEDICAL FINDINGS THE PATIENTMAY EVENTUALLY RETURN HOME OR BE DISCHARGED. If Yes, Check Only One Personal Care HomeServices provided in aPersonal Care Home ICF/ID CareServices to be provided at homeor in an Intermediate care facilityfor the intellectually disabled ICF/ORC CareServices to be provided at homeor in an Intermediate care facilityfor consumers with ORCs InpatientPsychiatric Care Other (Please Specify) DATE TELEPHONE PHYSICIAN SIGNATURE PHYSICIAN (PRINTED NAME) Medical and other professional personnel of the Medicaid agency or its designee MUST evaluate each applicant222s or recipient222s need for admission by reviewing and assessing the evaluations required by regulations. 2. Improving 3. Deteriorating 1. Good 2. Limited 3. Poor YES NO Yes No 1. Within 180 days 2. Over 180 days Inhalation Therapy Special Dressings Irrigations Other (Specify) 1. Self 3. No 2. Under Supervision 2. With Minimal Assistance 3. With Total Assistance PRIMARY (Principal) SECONDARY TERTIARY DATE REVIEWER222S SIGNATURE AND TITLE American LegalNet, Inc. www.FormsWorkFlow.com