DHCF PRESCRIPTION ORDER FORM (POF)

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)*

Telephone Number*

Phone

Secondary Telephone Number

Phone

Current Address*

E-mail Address

Current Medicaid Coverage*

Select

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?

Select or enter value

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)

If this is a “Change in Condition” request,please indicate how the condition has changed since the last assessment

Select or enter value

Comments: (describe the exact change from the selection above)

Request Type*

Select or enter value

Is this a hospital discharge

Select or enter value

Is this an initial nursing facility placement

Select or enter value

If yes, a completed Pre-Admission Screening Resident Review (PASRR) form is required to be attached/faxed to Liberty Healthcare

Is this a nursing facility conversion from MCO to LTC FFS

Select or enter value

Is this a nursing facility discharge for HCBS

Select or enter value

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

Physician/APRN Fax Number (Please note: requires additional submission, see confirmation email)

Physician/APRN E-mail Address:

Signature of Ordering Physician/APRN ( I have examined this patient and certify that long term care services and supports are medically necessary) :

Date

File Upload

Drag and drop files here or

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.

Send me a copy of my responses

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