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OHIO DEPARTMENT OF MEDICAID LEVEL OF CARE …

ohio DEPARTMENT OF MEDICAID . LEVEL OF care assessment . I. DEMOGRAPHICS assessment Date: / / II. REASON FOR REQUEST. a. Name a. NF Admission (check one of the following). New Admission b. Address Readmit: original date of admission Transfer: from c. Phone d. County original date of admission b. ICF / MR (name). e. DOB f. Age g. Sex: M F c. HCBS services (specify). d. ASSISTED LIVING. h. Language Spoken Barrier Y N e. RSS f. OC Review g. Other (specify). i. MEDICAID Active Pending If NF Admission: NF Name/Address j. Social Security Number k. Medicare Number Estimated Length of Stay Provider #. l. Date of Conversion from other Funding to MEDICAID III. LOC assessment SUMMARY. m. Other Health Insurance a.

odm 03697 (7/2014) formerly jfs 03697 (rev. 4/2003) ohio department of medicaid level of care assessment . i. demographics assessment date: / / ii. reason for request a.

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