DHCF PRESCRIPTION ORDER FORM (POF)

This form must be uploaded to DC Care Connect or forwarded to the DHCF assessment vendor. Items indicated with a * are required. The electronic prescription order form (ePOF) instruction page can be accessed at https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/publication/attachments/Prescription%20Order%20Form%20Instructions.pdf

SECTION l: PATIENT INFORMATION

Patient DC Medicaid Number (If the individual is new to DC Medicaid and does not yet have a Medicaid number, please note "N/A.”):

Patient First Name

Patient Last Name

Date of Birth (MM/DD/YYYY)

mm/dd/yyyy

Telephone Number

Phone

Secondary Telephone Number

Phone

Current Address

E-mail Address

Current Medicaid Coverage

Emergency Contact Name

Emergency Contact Telephone Number

Phone

Legal Guardian/POA Name

Legal Guardian/POA Telephone Number

Legal Guardian / POA Email Address

Primary Language Spoken

Are interpretive services needed at assessment?

SECTION ll. DETERMINING NEED FOR SERVICES

This patient has the following chronic medical/ ICD-IO code diagnosis(es):

Reason for referral to assessment

Recertification

Initial Assessment

Change in Condition

Upload (*by checking upload, you are attesting that this beneficiary has no change in functional level since the last MCO interRAI assessment)

Request Type

Is this a hospital discharge

Is this an initial nursing facility placement

Is this a nursing facility conversion from MCO to LTC FFS

Is this a nursing facility discharge for HCBS

Submitting individual

Submitter Name(Last, First)

Submitter Telephone Number

Phone

Submitter E-mail address

Today's Date

Please add any additional comments (If the submitter is not the direct contact for scheduling, please indicate the staff name and contact information below):

SECTION Ill: PHYSICIAN/APRN INFORMATION

Physician/APRN Name (Last, First):

Physician/APRN Telephone Number:

Phone

National Provider Identification Number:

Physician/APRN Address

Request for Physician/APRN signature

Fax

File Upload

Drop your files here

For individuals who wish to be enrolled in Medicaid-certified nursing facility, please send this form along with a completed Pre-Admission Screening Resident Review (PASRR) to the DHCF assessment vendor.

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