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Effective Date: 
11/2016

Documents

Instructions

Updated: 11/2016

Purpose

Form 2406 is used to document the medical fragility of an applicant requesting the Money Follows the Person option to apply for the Medically Dependent Children Program (MDCP) with a limited stay in a nursing facility.

Procedure

When to Prepare

Community Services Interest List (CSIL) staff complete Form 2406 when an applicant, applicant's parent or guardian requests a limited nursing facility stay.

Transmittal

CSIL staff mail the original form to the applicant, applicant's parent or guardian when an applicant requests a limited nursing facility stay within one calendar day of the contact.

Program Support Unit (PSU) staff upload a copy to the Health and Human Services Enterprise Administrative Report and Tracking System (HEART).

Retention

HEART is PSU's repository for the electronic case record. Paper copies of Form 2406 are not retained. PSU staff open a case record in HEART and upload a copy of the completed form to the system.

Supply Source

This form may be found in the STAR Kids Handbook or STAR Health Chapter 16.2 of the Uniform Managed Care Manual (UMCM).

Detailed Instructions

Completed by the applicant, applicant's parent or guardian:

Physician Name and Address— Enter the physician's name and address in the space provided.

Completed by the CSIL unit:

Community Services Interest List (CSIL staff) — Enter the CSIL staff member's name.

Office Address and Telephone No. — Enter the mailing address, including the street address or P.O. Box, city, state, ZIP code and telephone number.

CSIL No. — Enter the CSIL number assigned to the applicant.

Completed by the physician:

Your patient— Enter the applicant's name.

Date of Birth— Enter the applicant's date of birth.

Medically Fragile Criteria— The applicant's physician checks the appropriate boxes related to the applicant's condition and attaches physician documentation of chronic conditions.

Physician's Recommendation— The applicant's physician checks the box that reflects his recommendation of approving or not approving a nursing facility stay of at least 30 consecutive days.

Signature — MD/DO— The applicant's physician signs his name.

Date— The applicant's physician dates the form on the day of completion.

Telephone No.— The applicant's physician enters his area code and telephone number.

Name of MD/DO (Please print)— The applicant's physician prints his name.

License No.— The applicant's physician enters his license number.

Signature — Utilization Review Nurse — The Utilization Review nurse signs his name.

Date — The Utilization Review nurse dates the form on the day the review is completed.