New Jersey Department of Human Services

Pediatric Medical Day Care Services

PRIMARY HEALTH CARE PROVIDER REPORT

ON MEDICAID BENEFICIARY

Identifying Information
1.	Name of Beneficiary (Last, First, MI):
Address:
Telephone Number:
2.	Sex: Male Female	Age:	Birthdate:
3.	Medicaid Number:
4.	Social Security Number:
5.	Name of Parent/Guardian:
Address (if different from child’s):
Telephone Number:
Cell Phone Number:
authorization for release of health Information
I hereby authorize	to disclose health information and release the medical
records of	, the applicant/beneficiary to the New Jersey Department of Human
Services, as may be requested, for the purpose of determining eligibility for Pediatric Medical Day Care services.
Signature:
Date:
(Parent or Other Legal Representative)
health Information
1.	History (attach additional sheet if needed)
2.	Diagnosis
1.
2.
3.
(Add attachment for additional diagnoses)
3.	Medications
Name
Dosage
Route
Frequency
4.	Treatment Procedure/Plan
Type
Frequency
5.	Does child attend school? Yes No If Yes, number of days per week:
6.	Does child receive other services?
Private Duty Nursing	Yes No
If Yes, number of days per week:	Number of hours per day:
Home Health Care	Yes No
If Yes, number of days per week:	Number of hours per day:
Early Intervention	Yes No
If Yes, attach copy of the latest IFSP.
7.	Does child have special transportation needs?	Yes No
If yes, describe:
8.	Nursing care needs (check all appropriate on list):
Nutrition	Elimination	Cardiopulmonary Status	Mobility
Regular Diet	Appropriate for age	Monitoring Only	Appropriate for age
Special Diet	Bowel Incontinence (age >3)	CPAP/Bi-PAP	Prosthesis
Diabetic Shots	Urine Incontinence (age >3)	CP Monitor	Splints
Formula-Special	Ostomy, type:	Pulse Ox	Non ambulatory
N/G tube/G-tube/J-tube	Vital signs >2/day	>18 months old
Slow Feeder	Catheterization	Oxygen Therapy	Wheelchair
FTT or Premature	Home Dialysis	Vent
Hyperalimentation	Other (describe) **	Trach
Nebulizer Tx
Suctioning
Chest Physical Tx
Behavioral/Developmental	Integument	Neurological Status
Appropriate for age	Normal	Normal
Hyperactive	Burn Care	Deaf
Cooperative	Sterile Dressings	Blind
Alert	Decubiti	Seizures
Developmental Delay	Eczema-Severe	Paralysis
Mental Retardation	Other **	Neurological Deficit (describe)
Behavioral Problems*
Verbal
Non-Verbal
* Please describe Behavioral Problems, if checked:
** Other, describe:
9.	Name of Physician/Provider (Print):
Address:
Telephone Number:
Fax Number:
Signature of Physician:
Date Signed:

PRIMARY HEALTH CARE PROVIDER REPORT ON MEDICAID BENEFICIARY

(Continued)

ACS-11

OCT 14	Page 3 of 3 Pages.

OCT 14	Page 1 of 3 Pages.

ACS-11, Primary Health Care Provider Report

ACS-11, primary health care provider report, medicaid, pediatric medical day care services, aging and community services, ACS

Windows User

2014-10-31

human services