Form 2362 "Receipt Certification by a Qualified Rehabilitation Professional" - Texas

What Is Form 2362?

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

Form Details:

  • Released on September 1, 2020;
  • The latest edition provided by the Texas Health and Human 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 2362 by clicking the link below or browse more documents and templates provided by the Texas Health and Human Services.

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Download Form 2362 "Receipt Certification by a Qualified Rehabilitation Professional" - Texas

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Form 2362
September 2020-E
Nursing Facility Specialized Services (NFSS)
Receipt Certification by a Qualified Rehabilitation Professional
Instructions: Upon receipt of the customized manual wheelchair (CMWC), the authorizing therapist must coordinate with the
qualified rehabilitation professional (QRP) to verify that the CMWC meets the needs of the resident and that the specifications
are as intended. To receive a service authorization for the CMWC, this completed form must be uploaded to the LTC Online
Portal by the nursing facility (NF) after delivery and certification. The signature by the QRP on this form certifies the QRP was
present and involved in the clinical assessment and that the CMWC meets the needs of the individual as specified in the
assessment. If the NF fails to submit this receipt certification, HHSC will withhold the NF’s reimbursement for the CMWC.
Individual’s Name:
NFSS Document Locator No. (DLN):
Medicaid ID:
QRP First Name:
QRP Last Name:
QRP Certification No.:
QRP Certification Date:
I certify that I was present and involved in the clinical assessment for the CMWC and that the CMWC has been evaluated to fit
properly and meet the needs of the resident.
QRP Signature
Date
Note: To avoid requests being put in pending denial or denied status, ensure the signature and signature dates provided are
accurate and verifiable. Alterations to this form makes it invalid. Examples of alterations that invalidate this form include the use
of white out, cutting and pasting, and blacking out information. Alterations will result in the request being placed into a pending
denial status or denied. Errors may be corrected by drawing a single line through a mistake, writing the correction next to it and
initialing and dating the correction.
Form 2362
September 2020-E
Nursing Facility Specialized Services (NFSS)
Receipt Certification by a Qualified Rehabilitation Professional
Instructions: Upon receipt of the customized manual wheelchair (CMWC), the authorizing therapist must coordinate with the
qualified rehabilitation professional (QRP) to verify that the CMWC meets the needs of the resident and that the specifications
are as intended. To receive a service authorization for the CMWC, this completed form must be uploaded to the LTC Online
Portal by the nursing facility (NF) after delivery and certification. The signature by the QRP on this form certifies the QRP was
present and involved in the clinical assessment and that the CMWC meets the needs of the individual as specified in the
assessment. If the NF fails to submit this receipt certification, HHSC will withhold the NF’s reimbursement for the CMWC.
Individual’s Name:
NFSS Document Locator No. (DLN):
Medicaid ID:
QRP First Name:
QRP Last Name:
QRP Certification No.:
QRP Certification Date:
I certify that I was present and involved in the clinical assessment for the CMWC and that the CMWC has been evaluated to fit
properly and meet the needs of the resident.
QRP Signature
Date
Note: To avoid requests being put in pending denial or denied status, ensure the signature and signature dates provided are
accurate and verifiable. Alterations to this form makes it invalid. Examples of alterations that invalidate this form include the use
of white out, cutting and pasting, and blacking out information. Alterations will result in the request being placed into a pending
denial status or denied. Errors may be corrected by drawing a single line through a mistake, writing the correction next to it and
initialing and dating the correction.