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Maine DHHS - Edit Questionnaire - General


Status: Incomplete
   

General


1. Please describe the member's continued need for this level of care:



2. What has been the progress toward goals?

(Please select one.)


3. Provide an active strategy to improve progress toward goals during next review period:



4. Provide a description of how the provider will use the requested units in the next review period:



5. Is member engaged in treatment?

(Please select one.)

Instructions: A discharge plan should include a specific plan to decrease utilization, refer to appropriate level of care, and indicate the use of natural supports.

6. What is the discharge/transition plan?



7. What is the projected discharge/transition date?

Date:



8. What is the date of the most current diagnostic assessment?

Date:



9. Are there any medication changes since last request?

(Please select one.)


10. What are the symptoms since last review?




















11. Select the member's current living situation:

(Please select one.)


12. Select the member's current vocational/employment status:

(Please select one.)


13. Is this member of transition age (16-20 years)?

(Please select one.)


14. If the member has a guardian, is the guardian engaged in treatment?

(Please select one.)


15. Does the member require an interpreter?

(Please select one.)



Disclaimers (please check to confirm acceptance):