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Dmas 7

This form is used to assess an individual's need for personal care services and must be completed by a physician, physician assistant, or nurse practitioner. It collects information about the individual's ability to perform activities of daily living, mobility support needs, behavioral issues, and how often certain activities are engaged in. Once completed, the form is to be faxed to the Maternal and Child Health Division for prior authorization of personal care services based on eligibility criteria.

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1K views

Dmas 7

This form is used to assess an individual's need for personal care services and must be completed by a physician, physician assistant, or nurse practitioner. It collects information about the individual's ability to perform activities of daily living, mobility support needs, behavioral issues, and how often certain activities are engaged in. Once completed, the form is to be faxed to the Maternal and Child Health Division for prior authorization of personal care services based on eligibility criteria.

Uploaded by

Billie_anderson2473
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
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EPSDT Personal Care Services

Functional Status Assessment (DMAS-7)


Complete when personal care is ordered
This form must be completed by a Physician, Physicians Assistant or Registered Nurse
Practitioner

Name: Medicaid Number:


Date of Birth: Primary Diagnosis:
Parent/Guardian’s Name: Phone #:

Care needs must be related to a health condition and cannot be due to functional
limitations associated with the normal attainment of developmental milestones

Indicate how the individual performs the following support needs:


ADLS/Mobility Needs Help Performed by Others
Supports No Yes No Yes
Bathing
Dressing
Toileting
Transferring
Eating/Feeding
Continence-bowel
Continence-bladder
Ambulation

Indicate how often the individual engages in the following activities:

Behavioral Supports Harm Self or Others Threaten or Act Attempt Elopement


Aggressive
Daily
Weekly
Monthly
Every 3-4 months

Physician, Physicians Assistant or Nurse


Practitioner Name
(please print):
MD/PA/RNP Signature/ Date:

Provider ID #:

Fax completed form to: Maternal and Child Health Division /Fax – 804.225.3961
For questions about EPSDT email [email protected]

Receipt of personal care will depend on DMAS prior authorization


based on EPSDT Personal Care Services Criteria.

DMAS-7 February 5, 2008

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