Form 2605 is used for Medically Dependent Children Program (MDCP) waiver assessments to record the applicant’s, member’s or Legally Authorized Representative’s (LAR’s) review of the information recorded in the STAR Kids Screening and Assessment Instrument (SK-SAI) for those in STAR Kids or STAR Health.
When to Prepare or Update
The managed care organization (MCO) service coordinator or nurse assessor initiates the completion of this form for all initial assessments and reassessments of MDCP applicants and members.
Number of Copies
The original/electronic Form 2605 is maintained in the member's case record.
The MCO keeps Form 2605 according to the retention requirements found in all Medicaid managed care contracts and federal regulations. Keep all originals/electronic copies of this form in the member’s case record for five years after services are terminated.
1. Member or Applicant Name — Enter the name of the member or applicant as entered on the Screening and Assessment Instrument (SAI).
2. Member Medicaid No. or Social Security No. — Enter the nine-digit Medicaid number as entered on the SAI. If the applicant does not yet have a Medicaid number, enter the Social Security number.
3. Date of Birth — Enter the member’s/applicant's date of birth.
4. Name of Legally Authorized Representative (LAR) — Enter the member’s representative defined by state or federal law, including Texas Occupations Code § 151.002(6), Texas Health and Safety Code § 166.164 and Texas Estates Code Chapter 752.
a parent or legal guardian if the patient is a minor;
- a legal guardian if the patient has been adjudicated incompetent to manage the patient's personal affairs;
- an agent of the patient authorized under a durable power of attorney for health care;
- an attorney ad litem appointed for the patient;
- a guardian ad litem appointed for the patient;
- a personal representative or statutory beneficiary if the patient is deceased; or
- an attorney retained by the patient or by another person listed by this subdivision.
5. LAR Relationship to Member —Enter the LAR’s relationship to the applicant or member.
6. Date of Assessment — Enter the date the SK-SAI was conducted in the home.
7. I have reviewed the information captured in the STAR Kids Screening and Assessment Instrument (SK-SAI) – The applicant/member/LAR checks the box for “Yes” that they have reviewed the information captured in the SK-SAI or checks the box for “No” if they have now reviewed the information.
8a. If the assessment results in a pending denial status . . . — The applicant/member/LAR checks the box for “Yes” if they would like to request a peer-to-peer conversation between the MCO and a treating physician of their choice. The applicant/member/LAR checks the box for “No” if they do not want a peer-to-peer conversation.
8b. If yes, which treating physician . . . — If the box for “Yes” was selected in 8a., enter the name of the treating physician, specialty, address, area code and phone number. The treating physician does not have to be the applicant’s/member’s PCP but should be the same physician listed in the SAI.
9. Additional Feedback from Applicant/Member/LAR — Enter any additional information that the applicant/member/LAR feels would be useful, such as any discrepancies.
10. Additional Feedback from Nurse Assessor — Enter any additional information that the nurse assessor feels would be useful, such as any discrepancies.
11. How does applicant/member/LAR want to receive a copy of the completed SK-SAI . . . — Check the appropriate box for the applicant/member/LAR to receive a copy of the completed SK-SAI by mail (provide mailing address), by email (provide email address) or does not want an additional copy.
Check box if the applicant/member/LAR refuses to sign. — The nurse assessor checks the box if the applicant/member/LAR refuses to sign.
Signature of Applicant/Member/LAR — The applicant/member/LAR signs to certify the information captured on this form is correct.
Printed Name of Applicant/Member/LAR — The applicant/member/LAR types or prints his or her name.
Date — The applicant/member/LAR enters the date of signature.
Signature of Nurse Assessor — The nurse assessor signs to certify the information captured on this form is correct.
Printed Name of Nurse Assessor — The nurse assessor types or prints his or her name.
Date — The nurse assessor enters the date of signature.
Managed Care Organization — The nurse assessor enters the name of the MCO.