"Nursing Facility Post Eligibility Treatment of Income (Peti) Medical Necessity Certification Form" - Colorado

This "Nursing Facility Post Eligibility Treatment of Income (Peti) Medical Necessity Certification Form" is a document issued by the Colorado Department of Health Care Policy and Financing specifically for Colorado residents with its latest version released on February 1, 2017.

Download the up-to-date fillable PDF by clicking the link below or find it on the forms website of the Colorado Department of Health Care Policy and Financing.

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Nursing Facility Post Eligibility Treatment of Income (PETI)
Medical Necessity Certification Form
I certify that I consider the supplies and/or services included in this request to be medically
necessary and that there are no medical or cognitive contraindications to providing these
supplies and/or services.
________________________________________
____________
___________
Physician’s Signature (required)
License#
Date
Note: Only a physician’s signature is required to verify medical necessity
A Physician’s Assistant
.
(P.A.), Nurse Practitioner (N.P.), or Registered Nurse (R.N.) cannot sign for the physician.
________________________________________
____________
___________
Acupuncturist’s Signature
License#
Date
________________________________________
____________
___________
Audiologist/Otolaryngologist’s Signature
License#
Date
________________________________________
____________
___________
Dental Provider’s Signature
License#
Date
________________________________________
____________
___________
Vision Provider’s Signature
License#
Date
I agree to the purchase of the supplies and/or equipment covered by this request. I
understand that NF PETI may not cover the entire cost.
____________________________________________________
_________________
Signature of Client or Responsible Party (required)
Relationship
Note: an actual signature is required. Verbal consent is not an allowable option
.
COMPLETE NURSING FACILITY PETI CHECKLIST ON PAGE 2
1570 Grant Street, Denver, CO 80203-1818 P 303.866.4158 F 303.866.3991
February 2017
www.colorado.gov/hcpf
Nursing Facility Post Eligibility Treatment of Income (PETI)
Medical Necessity Certification Form
I certify that I consider the supplies and/or services included in this request to be medically
necessary and that there are no medical or cognitive contraindications to providing these
supplies and/or services.
________________________________________
____________
___________
Physician’s Signature (required)
License#
Date
Note: Only a physician’s signature is required to verify medical necessity
A Physician’s Assistant
.
(P.A.), Nurse Practitioner (N.P.), or Registered Nurse (R.N.) cannot sign for the physician.
________________________________________
____________
___________
Acupuncturist’s Signature
License#
Date
________________________________________
____________
___________
Audiologist/Otolaryngologist’s Signature
License#
Date
________________________________________
____________
___________
Dental Provider’s Signature
License#
Date
________________________________________
____________
___________
Vision Provider’s Signature
License#
Date
I agree to the purchase of the supplies and/or equipment covered by this request. I
understand that NF PETI may not cover the entire cost.
____________________________________________________
_________________
Signature of Client or Responsible Party (required)
Relationship
Note: an actual signature is required. Verbal consent is not an allowable option
.
COMPLETE NURSING FACILITY PETI CHECKLIST ON PAGE 2
1570 Grant Street, Denver, CO 80203-1818 P 303.866.4158 F 303.866.3991
February 2017
www.colorado.gov/hcpf
NURSING FACILITY PETI CHECKLIST
Complete appropriate checklist for each request
Health Insurance Premiums
☐ Resident’s monthly patient payment - $_____________
☐ Medical Necessity Form completed with:
☐ Signature of Attending Physician
☐ Signature of Client Responsible party
☐ Verification of premium amount
☐ Insurance Card – front and back
☐ Months of coverage being requested: _______________
_______________
not to exceed 12 months
From
To
Acupuncture
☐ Resident’s monthly patient payment - $_____________
☐ Medical Necessity Form completed with:
☐ Signature of Attending Physician
☐ Signature of Client Responsible party
☐ Signature of Provider
☐ Provider’s invoice with procedure codes and fees
☐ Prescription/Dr. Orders with number of treatments
Dental
☐ Resident’s monthly patient payment - $_____________
☐ Medical Necessity Form completed with:
☐ Signature of Attending Physician
☐ Signature of Client Responsible party
☐ Signature of Provider
☐ Provider’s invoice with procedure codes and fees
☐ DentaQuest EOB verifying $1000 Medicaid benefit is exhausted
Hearing
☐ Resident’s monthly patient payment - $_____________
☐ Medical Necessity Form completed with:
☐ Signature of Attending Physician
☐ Signature of Client Responsible party
☐ Signature of Provider
☐ Provider’s invoice with procedure codes and fees
☐ Audiogram – performed by licensed audiologist no older than one year (for Hearing Aids only)
(Note: BC HIS is not an acceptable license to perform the audiogram)
Vision
☐ Resident’s monthly patient payment - $_____________
☐ Medical Necessity Form completed with:
☐ Signature of Attending Physician
☐ Signature of Client Responsible party
☐ Signature of Provider
☐ Provider’s invoice with procedure codes and fees
February 2017
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