DOH-4359 (2010) PHYSICIAN'S ORDER FOR PERSONAL CARE/CONSUMER DIRECTED PERSONAL ASSISTANCE SERVICES COWPLETE ALL ITEMS INCOMPLETE FORMS WILL SE RETURNED TO THE PHYSICIAN 4_Patient Identifying Information (Use Adeitional Paper It Necessary) PATIENT WANE: en ATE OF RTH sex a sare POOOE AODRESE TS FELEHONEN VEDAS fi i TO ABOVE ADDRESS? D) VES LINO FNOBIPLAN: oR ORE ATE PESTS (A 2. General information PHYSICIAN NAME [NOENSE [TELEPHONE NO. eis) RODRESS: STREET av STATE IP CODE Tine sxarinalion was conducled by a Physican’s Assstar, Gpecaliats Assistant, or Nurse Pracioner, Hentiy Name Profession: Loense #, PLACE OF EXAMINATION: DATE OF EXAMINATION: 3 Medical Findings NOTE: Inclate NIA anitem does not apply to this patient or Unk the requested information is unknown to he physician slgning this form, Height: Wri Forte coelton(s) equting personal care Primary Diagnosis IoD-s.0M Code Secondary Diagnosis loD-3.cM Goce DDaverbe the patent's curent medicalphysical condition Te the patients condition stable? CI Yes 11 No lathe patent approprsts for Hospice care? CI] Yes] No Deter the curent raiment plan and therapeute goals including the prognosis for recovery DDoverbe any proitited actives or functional imitations: isthe patienteeltdtecing? [] Yes [1 No Is he patient sbi to summon help by any means? C] Yes C] No iro, explain Isthe patentable toambulate independent? [I Yes [] No Witdevicos? C] Yes [J No Other Assistance? CI Yee CI] No Deserbe: Iethe patient contnentof bowel? C] Yes [] No ofbladser? O] Yes No CatheterColostomy Needs: Lista rent medications (prescription and OTC) and pote dosage and frequency and ary special instructions attach addionalshestif necessary): Can the patient self-administer medications: C1 Yes 1 NoIfthe patient requires @ modifed eto has ober special muons or dietary needs, describe: Please indlcste any tes, treatments o: therapies curently received, or oquited by the pation Does the patient require eesstance wth, or provision of, skilled tasks (eg. monitoring of val signs, cressing changes, olucose moritring, eta)? D Yes O No 1fYes, please indicate: Based on the mecieal condition, do you rocommend te provcon of sorvco fo asst wit eld seks, personal care andlor ight ousskespingt Dyes Ono Contributing Factors Desc contbuting factors including but rot lined to the social, family, home or medical e.g. musculaiotor impairments, poor range of otcn, decreases etamina ate) situation that may affect the patients ability to function, or may affect the nes for home cate or that may affect the pens need ‘or ssstsnce with sled tasks, personal cae tasks andlor ight housekeeping. Please ince any cter information that may be pertinent to the nee for assistance ith hora care serves ITISMY OPINION THAT THIS PATIENT CAN BE CARED FOR AT HOME | HAVE ACCURATELY DESCRIBED HIS OR HER MEDICAL CONDITION. NEEDS AND REGIMENS, INCLUDING ANY MEDICATIONREGIMENS, AT THE TIME | EXAMINED KIM OR HER. | UNDERSTAND THAT | Atl NOT TO RECOMMEND THE NUMBER OF HOURS OF PERSONAL CARE SERVICES THIS PATIENT MAY REQUIRE. ALSO UNDERSTAND THAT THIS PHYS! CIAN'S ORDER IS SUBLECT TO THE NEW YORK STATE DEPARTMENT OF HEALTH REGULATIONS AT PARTS 515, 510,517 AND S18 OF TITLE 18 NYCRR, WHICH PERMIT THE DEPARTMENT TO IMPOSE MONETARY PENALTIES ON, OR SANCTION AND RECOVER OVERPAYMENTS FROM, PROVIDERS OR PRESCRISERS OF MEDICAL CARE, SERVICES OR SUPPLIES WHEN MEDICAL CARE, SERVICES OR SUPPLIES THAT ARE UNNECESSARY, IMPROPER OR EXCEED THE PATIENT'S DOCUMENTED MEDICAL CONDITION ARE PROVIDED OR ORDERED, INCOMPLETE OR MISSING INFORMATION MAY DELAY SERVICES TO THIS PATIENT Physiclan's Signature Date PLEASE SIGN AND RETURN COMPLETED FORM WITHIN 30 CALENDAR DAYS OF EXAMINATION TO: New York State Department of Health 2.