Care Expense Questions

Discussion in 'General Discussion' started by Max, Jul 2, 2010.

  1. Max

    Max Hero Member

    Someone asked earlier what questions need to be answered in order to have continuing care counted as a medical expense. Listed below is the full text of what is asked.


    Veteran’s name: ______
    Patient’s name: ______
    Name of facility or care provider:
    Phone number of facility or care provider:
    Address of facility or care provider: ______


    Date entered facility or in-home care began:
    Date patient left facility (if applicable): ____________________________________
    Will the patient need this care indefinitely? 0 Yes 0 No
    If No, when will the care end?
    Has the patient applied for Medicaid? 0 Yes 0 No

    Is part of the patient’s cost covered by Medicaid, Medicare, or insurance?
    0 Yes 0 No
    When did coverage begin?

    What monthly amount does the claimant or patient pay from his/her own funds?

    Current rate Rate:$ per month
    Effective Date:
    Prior Rate (if applicable) Rate:$ per month
    Effective Date:






    FOR NURSING HOME CARE ADD:

    Is your facility licensed by the State? 0 Yes 0 No
    Is your facility Medicaid approved? 0 Yes 0 No
    Is the patient in your nursing home because of a physical or mental disability? 0 Yes 0 No
    Do you provide either skilled or intermediate level nursing care to the patient? 0 Yes 0 No

    What was the admitting diagnosis?





    FOR IN HOME CARE ADD:

    Do you provide any medical or nursing services for the patient? (i.e. administering medication; physical or mental therapy; assisting with personal hygiene, dressing, bathing; etc.) 0 Yes 0 No

    Describe the services you provide:


    Are you a licensed health professional? (registered nurse, licensed vocational nurse, or licensed practical nurse) 0 Yes 0 No

    If Yes, provide your license number:

    If you charge by the hour, please list your hourly rate and weekly hours worked:

    Hourly Rate: Weekly Hours:







    FOR OTHER TYPES OF CARE FACILITIES ADD:

    Indicate type of facility: 0 Foster Home 0 Adult Day Care 0 Rest Home
    0 Group Home 0 Assisted Living

    Do you provide any medical or nursing services for the patient? (i.e. administering medication; physical or mental therapy; assisting with personal hygiene, dressing, bathing; etc.) 0 Yes 0 No

    Describe the services you provide:




    If the patient receives medical or nursing services, are the services provided or supervised
    by a licensed health professional? (registered nurse, licensed vocational nurse, or licensed practical nurse) 0 Yes 0 No
    We must have the monthly charge broken down into the following two categories:

    1. Base Rate (includes room, meals, laundry, housekeeping): $ per month

    2. Medical and Nursing Services: $ per month



    SIGNATURES:


    I certify that the above statements are true and correct to the best of my knowledge and belief.

    Signature of facility administrator or care provider Date



    I certify that the above statements are true and correct to the best of my knowledge and belief. I am paying $ per month for my care from my own funds. ______ Signature of veteran or beneficiary Date
     

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