Form NMO-7073 "Nevada Medicaid: Functional Assessment Service Plan" - Nevada

What Is Form NMO-7073?

This is a legal form that was released by the Nevada Department of Health and Human Services - a government authority operating within Nevada. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on October 1, 2015;
  • The latest edition provided by the Nevada Department of Health and Human Services;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form NMO-7073 by clicking the link below or browse more documents and templates provided by the Nevada Department of Health and Human Services.

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Download Form NMO-7073 "Nevada Medicaid: Functional Assessment Service Plan" - Nevada

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Page background image
Recipient Name:
Recipient ID:
Nevada Medicaid: Functional Assessment Service Plan
Recipient Signature Page
1. Recipient information
Last name:
First name:
Recipient ID:
Date of birth:
No
Translator required:
Yes
Language:
Address:
City:
State:
Zip code:
Phone:
NV
Female
Male
HT:
Feet
Inches
WT:
Age:
1.
I, my Legally Responsible Individual, or personal care representative participated in the assessment process,
providing accurate information to the best of my/their ability.
2.
The physical/occupational therapist arrived (enter date of the assessment, along with the start and end times of
the assessment):
Date:
Begin time:
a.m.
p.m.
End time:
a.m.
p.m.
By signing below, I acknowledge the above information is correct. My signature does not indicate that I agree or
disagree with the final outcome of the assessment.
Print Name (Recipient/LRI/PCR)
Signature
Date
Identify relationship of person signing this form:
Self
Legally Responsible Individual (LRI)
Personal Care Representative (PCR)
Other (please specify):
NO
At Risk Recipient:
YES
Date of Assessment:
2. Legally responsible individual (LRI) information (if applicable)
LRI name:
Phone:
Relationship to
Does LRI reside in the home with
recipient:
recipient?
Yes
No
Identify the living arrangements of the LRI:
Resides in the Home
Disabled
Works/Attends school (specify hours/days):
Page 1 of 8
Functional Assessment and Service Plan
NMO-7073 (10-15)
Recipient Name:
Recipient ID:
Nevada Medicaid: Functional Assessment Service Plan
Recipient Signature Page
1. Recipient information
Last name:
First name:
Recipient ID:
Date of birth:
No
Translator required:
Yes
Language:
Address:
City:
State:
Zip code:
Phone:
NV
Female
Male
HT:
Feet
Inches
WT:
Age:
1.
I, my Legally Responsible Individual, or personal care representative participated in the assessment process,
providing accurate information to the best of my/their ability.
2.
The physical/occupational therapist arrived (enter date of the assessment, along with the start and end times of
the assessment):
Date:
Begin time:
a.m.
p.m.
End time:
a.m.
p.m.
By signing below, I acknowledge the above information is correct. My signature does not indicate that I agree or
disagree with the final outcome of the assessment.
Print Name (Recipient/LRI/PCR)
Signature
Date
Identify relationship of person signing this form:
Self
Legally Responsible Individual (LRI)
Personal Care Representative (PCR)
Other (please specify):
NO
At Risk Recipient:
YES
Date of Assessment:
2. Legally responsible individual (LRI) information (if applicable)
LRI name:
Phone:
Relationship to
Does LRI reside in the home with
recipient:
recipient?
Yes
No
Identify the living arrangements of the LRI:
Resides in the Home
Disabled
Works/Attends school (specify hours/days):
Page 1 of 8
Functional Assessment and Service Plan
NMO-7073 (10-15)
Recipient Name:
Recipient ID:
Nevada Medicaid: Functional Assessment Service Plan
3. Emergency contact information
Complete this section if recipient has no LRI (such as: POA, family member, personal care representative).
Contact Name:
Phone:
(other than recipient)
Relationship to
Recipient:
4. Daily routine (Describe recipient’s usual daily routine)
5. Assessment information
Purpose of request:
Location:
Information obtained from:
Initial
House
Apartment
Recipient
Annual Reassessment
Mobile Home
Facility
Other:
Significant Change in
SLA (Supportive Living arrangement)
Condition
Other:
Name of personal care services (PCS) agency:
Name of personal care aide (PCA):
Others in household (if children, include ages
of the children):
Allergies (medications, foods, seasonal):
6. Diagnosis affecting functional ability to complete activities of daily living (ADLs) and instrumental activities of daily
living (IADLs). For example: affected limbs, affected gait, strength, endurance, etc.
Diagnosis
Diagnosis
Diagnosis
7. Medications
Medication/dosage/frequency
Medication/dosage/frequency
Page 2 of 8
Functional Assessment and Service Plan
NMO-7073 (10-15)
Recipient Name:
Recipient ID:
Nevada Medicaid: Functional Assessment Service Plan
8. Objective observations of functional ability including serious events over the past year
9. Functional deficits (check all that apply)
Mobility
Mobility/Range of motion:
Gait:
Independent
Independent with Device
Mildly impaired
Moderately impaired
Severely impaired
Non-ambulatory
Bed bound
Other/Comment:
Dominant Side:
Right
Left
N/A
Right Arm:
Full Use
Mildly impaired
Moderately impaired
Severely impaired
Other/Comment:
Left Arm:
Full Use
Mildly impaired
Moderately impaired
Severely impaired
Other/Comment:
Right Leg:
Full Use
Mildly impaired
Moderately impaired
Severely impaired
Other/Comment:
Left Leg:
Full Use
Mildly impaired
Moderately impaired
Severely impaired
Other/Comment:
10. Sensory deficits (check all that apply)
Vision:
Within normal limits without glasses
Within normal limits with glasses
Glasses
Reading glasses
Vision Impaired:
Right Eye:
Partially impaired
Blind
Other/Comment:
Left Eye:
Partially impaired
Blind
Other/Comment:
Both Eyes:
Partially impaired
Blind
Other/Comment:
Page 3 of 8
Functional Assessment and Service Plan
NMO-7073 (10/15)
Recipient Name:
Recipient ID:
Nevada Medicaid: Functional Assessment Service Plan
10. Sensory deficits (check all that apply)
Auditory:
Within normal limits with or without hearing aids
Decreased hearing:
Hearing aids
Deaf
Other/Comment:
Pain (affecting ability to do ADLs/IADLs):
Pain scale 0 to 10:
If >0 indicate location/type of pain:
Other/Comment:
Touch/Sensation:
Within normal limits
Other/Comment:
11. Cognitive deficits (check all that apply)
Memory/Cognitive:
Within normal limits
Not oriented
Oriented to:
Person
Place
Time
Other/comment:
Short term memory loss:
Mild
Moderate
Severe
Other/Comment:
Object Recognition:
Mild
Moderate
Severe
Other/Comment:
Requires cueing:
Able to follow detailed directions
Able to follow simple directions
Unable to follow simple directions
Other/Comment:
Speech/Language:
Within normal limits (able to express and understand)
Slurred speech
Non verbal
Aphasia:
Expressive (difficulty expressing words/sentences)
Receptive (difficulty understanding words/sentences)
Global (difficulty expressing and understanding words/sentences)
Other/Comment:
Page 4 of 8
Functional Assessment and Service Plan
NMO-7073 (10/15)
Recipient Name:
Recipient ID:
Nevada Medicaid: Functional Assessment Service Plan
12. Endurance deficits - the ability to withstand activities (check all that apply)
Within normal limits
Shortness of breath
Inability to stand > 10 minutes
Fatigues with activity of > 10 minutes
Other(describe):
13. Assistive devices and other services (check all that apply)
Equipment: H=Has U=Uses N=Needs
Services: R=Receives N=Needs
H U N
H U
N
R N
R N
Lift/Hoyer
Walker
ADSD aging and disability services
Commode
Oxygen
Disability waiver (WIN)
Bath/Shower Bench
Lifeline
Dental
Medical
Manual Chair
Slide Board
Ocular
Audiology
Incontinent Supplies
Hospital Bed
Physical Therapy
Raised Toilet Seat
Diabetic Supplies
Occupational Therapy
Hand Held Shower
Glucometer
Home Health
Nebulizer
Power Chair
MHDS
ADHC
Cane Crutches
Companion
Respite
Other:
Homemaker
Other:
Transportation
Other
Home Delivered Meals
Chore
Other
Note: A box marked “N” does not guarantee Medicaid coverage for that item or service.
Services (check if currently receiving)
ADHC
Work Program
Attends
days per week
hours per day
Attends
days per week
hours per day
School
Attends
days per week
hours per day
Comments:
Page 5 of 8
Functional Assessment and Service Plan
NMO-7073 (10/15)
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