Form HFS3701G "Special Decubitus Mattress Questionnaire" - Illinois

What Is Form HFS3701G?

This is a legal form that was released by the Illinois Department of Healthcare and Family Services - a government authority operating within Illinois. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

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

Download a fillable version of Form HFS3701G by clicking the link below or browse more documents and templates provided by the Illinois Department of Healthcare and Family Services.

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Download Form HFS3701G "Special Decubitus Mattress Questionnaire" - Illinois

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State of Illinois
Department of Healthcare and Family Services
Special Decubitus Mattress Questionnaire
RIN:
DOB:
Patient Name:
Individual answers to all of the questions are required for rental consideration of pressure pads and mattress
overlays. These questions should be answered by the home health agency registered nurse or the attending
physician; all of the information must be reviewed and signed by the attending practitioner. An updated form is
needed for each renewal that includes a dated wound assessment less than seven days old at the time of
submission of the request.
1. Provide complete list of primary and secondary diagnoses as well as comorbidities and complicating factors
such as chemotherapy, transplant recipient, dementia, obesity, nutritional deficiencies, mobility limitations,
impaired sensation, hip or knee replacement, fracture, and caregiver health impairments.
2. Provide complete description of any areas of skin breakdown including etiology (pressure, surgical, vascular-
venous stasis/arterial, neuropathic/diabetic, traumatic), measurements (length x width x depth), wound bed
characteristics (granulation tissue, slough, and eschar), presence of infection, margins for tunneling and
undermining, drainage (type and amount), age of wound(s), and staging for pressure wounds.
3. Is the patient presently on a pressure-relief system or been on an ulcer treatment program for at least the last
month that has included the use of a non-powered pressure reducing overlay/mattress or alternating pressure
pad? Describe further.
HFS 3701G (R-2-15)
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State of Illinois
Department of Healthcare and Family Services
Special Decubitus Mattress Questionnaire
RIN:
DOB:
Patient Name:
Individual answers to all of the questions are required for rental consideration of pressure pads and mattress
overlays. These questions should be answered by the home health agency registered nurse or the attending
physician; all of the information must be reviewed and signed by the attending practitioner. An updated form is
needed for each renewal that includes a dated wound assessment less than seven days old at the time of
submission of the request.
1. Provide complete list of primary and secondary diagnoses as well as comorbidities and complicating factors
such as chemotherapy, transplant recipient, dementia, obesity, nutritional deficiencies, mobility limitations,
impaired sensation, hip or knee replacement, fracture, and caregiver health impairments.
2. Provide complete description of any areas of skin breakdown including etiology (pressure, surgical, vascular-
venous stasis/arterial, neuropathic/diabetic, traumatic), measurements (length x width x depth), wound bed
characteristics (granulation tissue, slough, and eschar), presence of infection, margins for tunneling and
undermining, drainage (type and amount), age of wound(s), and staging for pressure wounds.
3. Is the patient presently on a pressure-relief system or been on an ulcer treatment program for at least the last
month that has included the use of a non-powered pressure reducing overlay/mattress or alternating pressure
pad? Describe further.
HFS 3701G (R-2-15)
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4. Provide details of past and present wound treatment plan that include but are not limited to the following as
relevant:
a. Education of patient and caregivers
b. Optimization of nutritional deficiencies
c. Treatment of anemia
d. Incontinence management
e. Measures to offload pressure and reduce risk of shear
f.
Improvement of glucose control for diabetics
g. Infection of wound and/or osteomyelitis
h. Topical antimicrobials
i.
Growth factors, skin substitutes, electromagnetic therapy, electrical stimulation, hyperbaric oxygen,
thermal ultrasound, topical collagen, and extracellular matrix protein
j.
Compression for venous insufficiency
k. Revascularization for arterial insufficiency
l.
Surgical intervention (flap, graft)
m. Debridement (surgical, enzymatic)
n. Negative pressure wound therapy
o. Low intensity ultrasound saline therapy
Practitioner's Signature with degree:
Date
NPI:
Office Phone #:
Fax:
HFS 3701G (R-2-15)
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