You must complete ques= tions 1 – 3 and sign this form, in order for the following member
Name:__________= ________________________ Date of Birth: ________________ to receive:
□ Physical Therapy &= nbsp; &nbs= p; □ Occupational Therapy = ; &n= bsp; □ Speech-Language Therapy
The Department of Heal= th and Human Services adopted a change to the MaineCare Benefits Manual on January= 20, 2006 to Section 40, Home Health Services. This rule change added a rehabilitation potential prerequisit= e for adults receiving occupational, physical, and/or speech-language therapy services reimbursed under MaineCare Home Health Services. A referral request for therapy ser= vices must include a copy of this form, which serves as your documentation of the member’s rehabilitation potential.
Rehabilitation Potentia= l is the documented expectation by a physician of measurable, “function= ally significant improvement” (the demonstrable, measurable increas= e in the individual’s ability to perform specific tasks or motions that contribute to independence outside the therapeutic environment), in the member’s condition in a reasonable, predictable period of time as the result of the prescribed treatment plan.
1. I
assessed the member by:
□ Phone
□ Examinatio= n
□ Therapist evaluation
□ Other, please explain_________________________________________________________
2.=
I certify that the member has
rehabilitation potential for his or her complaint/diagnosis of
__________________ because of a/an:
&n= bsp; □ Acute condition
&n= bsp; □ Acute exacerbation of chronic condition
&n= bsp; □ Past response to therapy
&n= bsp; □ Other, please explain:_____________________________________________________= ____
3.= I expect the member to attain meas= urable functional improvement, because of the following indicators:
____________________________________________________= ______________________________
____________________________________________________= ______________________________
I certify (or re-certify) that it is medically necessa= ry for this patient to receive physical, occupational and/or speech–language therapy and that the therapies meet the MaineCare rehabilitation potential criteria. The patient is unde= r my care, and I have authorized these therapies as part of the plan of care and will periodically review the plan for continued rehabilitation potential.
Dr. ______________________________________ ______________________________________
&=
nbsp; (Physician’s
Signature) =
; &n=
bsp; =
; (Print
Physician’s Name)
Please fax to (HHA) @ (fax number)
DRAFT