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DEPARTMENT OF HEALTH SERVICES Division of Medicaid Services F01020 (02/2017) STATE OF WISCONSIN Wis. Admin. Code DHS 107.09(4)(h) FORWARDHEALTH NURSING HOME CARE DETERMINATION REQUEST Instructions:
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How to fill out nursing home care determination

01
Gather all necessary documentation, such as medical records and health assessment forms.
02
Fill out the nursing home care determination form accurately and completely.
03
Provide detailed information about the individual's medical condition, daily living activities, and personal needs.
04
Include any supporting documentation or additional information that is relevant to the determination process.
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Submit the completed form and supporting documents to the appropriate authority or agency responsible for nursing home care determinations.
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Follow up with the authority or agency to ensure the process is moving forward and to address any additional requirements or questions.

Who needs nursing home care determination?

01
Individuals who require significant assistance with activities of daily living, such as bathing, dressing, eating, and mobility.
02
Individuals who have complex medical conditions that cannot be managed at home or in a less intensive care setting.
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Individuals who have cognitive impairments or dementia and require specialized care and supervision.
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Individuals whose family or caregivers are unable to provide the necessary level of care and support.
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Individuals who have recently been discharged from a hospital and require further rehabilitation or skilled nursing care.
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Individuals who have terminal illnesses and require palliative or end-of-life care.
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Individuals who have experienced a significant decline in their physical or mental health and can no longer safely live at home.
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Nursing home care determination is the process of assessing an individual's eligibility for long-term care in a nursing home facility.
The individual or their legal representative is required to file nursing home care determination.
To fill out nursing home care determination, one must provide necessary information such as medical history, financial status, and care needs.
The purpose of nursing home care determination is to ensure that individuals receive appropriate and necessary long-term care in a nursing home facility.
Information such as medical history, financial status, and care needs must be reported on nursing home care determination.
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2017 WISCONSIN MDS CMS ZIP4 Taxonomy Preadmission PASRR Facesheet 01020A DHS Submittal FORWARDHEALTH Wis Identifier Providers developmental submitting Admin LOC Medicare Medicaid completing specialized II Revised Physicians PROVIDER Completion summary

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