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    Dmas 7

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    Billie_anderson2473
    This form is used to assess an individual's need for personal care services and must be completed by a physician, physician assistant, or nurse practitioner. It collects information about the individual's ability to perform activities of daily living, mobility support needs, behavioral issues, and how often certain activities are engaged in. Once completed, the form is to be faxed to the Maternal and Child Health Division for prior authorization of personal care services based on eligibility criteria.

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    Dmas 7

    Uploaded by

    Billie_anderson2473
    1K views1 page
    This form is used to assess an individual's need for personal care services and must be completed by a physician, physician assistant, or nurse practitioner. It collects information about the individual's ability to perform activities of daily living, mobility support needs, behavioral issues, and how often certain activities are engaged in. Once completed, the form is to be faxed to the Maternal and Child Health Division for prior authorization of personal care services based on eligibility criteria.

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    DMAS 7

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    This form is used to assess an individual's need for personal care services and must be completed by a physician, physician assistant, or nurse practitioner. It collects information about the individual's ability to perform activities of daily living, mobility support needs, behavioral issues, and how often certain activities are engaged in. Once completed, the form is to be faxed to the Maternal and Child Health Division for prior authorization of personal care services based on eligibility criteria.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    1K views1 page

    Dmas 7

    Uploaded by

    Billie_anderson2473
    This form is used to assess an individual's need for personal care services and must be completed by a physician, physician assistant, or nurse practitioner. It collects information about the individual's ability to perform activities of daily living, mobility support needs, behavioral issues, and how often certain activities are engaged in. Once completed, the form is to be faxed to the Maternal and Child Health Division for prior authorization of personal care services based on eligibility criteria.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    EPSDT Personal Care Services

    Functional Status Assessment (DMAS-7)


    Complete when personal care is ordered
    This form must be completed by a Physician, Physicians Assistant or Registered Nurse
    Practitioner

    Name: Medicaid Number:


    Date of Birth: Primary Diagnosis:
    Parent/Guardian’s Name: Phone #:

    Care needs must be related to a health condition and cannot be due to functional
    limitations associated with the normal attainment of developmental milestones

    Indicate how the individual performs the following support needs:


    ADLS/Mobility Needs Help Performed by Others
    Supports No Yes No Yes
    Bathing
    Dressing
    Toileting
    Transferring
    Eating/Feeding
    Continence-bowel
    Continence-bladder
    Ambulation

    Indicate how often the individual engages in the following activities:

    Behavioral Supports Harm Self or Others Threaten or Act Attempt Elopement


    Aggressive
    Daily
    Weekly
    Monthly
    Every 3-4 months

    Physician, Physicians Assistant or Nurse


    Practitioner Name
    (please print):
    MD/PA/RNP Signature/ Date:

    Provider ID #:

    Fax completed form to: Maternal and Child Health Division /Fax – 804.225.3961
    For questions about EPSDT email epsdt@dmas.virginia.gov

    Receipt of personal care will depend on DMAS prior authorization


    based on EPSDT Personal Care Services Criteria.

    DMAS-7 February 5, 2008

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