Form MAD754 Attachment B "Weighted Standardized Health Risk Assessment (HRA)" - New Mexico

What Is Form MAD754 Attachment B?

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

Form Details:

  • Released on March 18, 2018;
  • The latest edition provided by the New Mexico Human Services Department;
  • 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 printable version of Form MAD754 Attachment B by clicking the link below or browse more documents and templates provided by the New Mexico Human Services Department.

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Download Form MAD754 Attachment B "Weighted Standardized Health Risk Assessment (HRA)" - New Mexico

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18-07
April 5, 2018
18-07
April 5, 2018
Attachment B: Weighted HSD Standardized Health Risk Assessment
Health Risk Assessment (HRA)
CNA Required for Items in
BLUE
Member’s Name (First, Middle, Last)
Member’s Medicaid ID
Date
Has Member Given Permission for Another Person to
Name of Person Completing/Assisting with the Completion
Complete this form?
of This Assessment and Their Relationship to Member
Yes
No
Member’s Address
City
City
State
State
Zip
Zip
Home Phone
Cell Phone
Other Phone
Emergency Contact Name/Phone
Date of Birth
Assessment Method
Demographics Verified?
Telephonic
In-person
Other
Yes
No
Assessment Type
Initial assessment
Reassessment
Change in health status
Question
Response
Do you have a language need other than
English?
Yes
No
1.
Do you need translation services?
Yes
No
Please describe:
Cultural preference
Hearing Impairment
Literacy
Do you have any special preferences we should
2.
Religion/Spiritual needs or preferences
be aware of?
Visual Impairment
None
Other (describe):
3.
What is your main health concern right now?
Behavioral health diagnosis
(CNA required)
Comorbid conditions
(CNA required)
ICF/MR/DD
(CNA required)
High risk pregnancy
(CNA required)
4.
Do you have any current or past physical and/or
Transplant patient
(CNA required)
behavioral health conditions or diagnoses?
Medically Fragile Waiver Program
(CNA required)
Medically frail
(CNA required)
Traumatic brain injury
(CNA required)
Other acute or terminal disease:
(CNA required)
(Adult only question) Compared to others your
Excellent
Very Good
Good
5.
age, would you say your health is…..?
Fair
Poor
Do you have any pending physical health
procedures or behavioral health appointments?
Yes
No
(if yes, CNA required)
6.
Date of most recent physical examination or
medical appointment:
Yes
No
Have you visited the Emergency Room in the
past 6 months?
1
2
3
4
5
6
7
8
9
10 or more
If yes, how many visits?
7.
(if 2 or more, CNA required)
Date(s) of ER visit(s):
Reason for ER visit(s):
MAD 754 Revised 3/18/18
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Question
Response
Have you stayed overnight in the hospital in the
past 6 months?
Yes
No
8.
If yes, how many times?
1
2
3
4
5
6
7
8
9
10 or more
If yes, were you readmitted within 30 days of
(if 2 or more, CNA required)
discharge?
Yes
No
(if yes, CNA required)
How many medicications are you currently
1
2
3
4
5
6 or more
9.
taking?
(if 6 or more, CNA required)
Homeless (CNA req.)
Living alone
Living in group home
Living in shelter (CNA req.)
Living with other family
Living with others unrelated
Living with spouse
What is your current living situation?
Living in assisted living facility
10.
Lives in out of state facility (CNA required)
Lives in out of home placement
Dependent child in out of home placement (CNA req.)
Living in a nursing facility
Other (describe):
Do you need assistance with 2 or more of the
Yes
No
(If yes, CNA required)
following?
Dressing
Bathing/grooming
Eating
Meal acquisition/preparation
Transfer
11.
Mobility
Toileting
Bowel/bladder
Daily medication
Other:
Is your need for assistance being met today?
Yes
No
Do you need or are you interested in Long-
12.
Yes
No
Term Care services?
An advance directive is a form that lets your
Living will
loved ones know your health care choices if you
Advance directive (for medical care)
are too sick to make them yourself. Do you
Advance directive (for psychiatric care)
13.
have a living will or an advance directive in
No living will or advance directive in place
place?
Declined discussion
Could I send you more information?
Requested further information
Are you interested in receiving Care
14.
Coordination Services?
Yes
No
The MCO shall provide the following information to every Member during his or her HRA:
1. Information about the services available through Care Coordination
2. Information about the Care Coordination Levels (CCLS)
3. Notification of the Member’s right to request a higher Care Coordination Level
4. Requirement for an in-person Comprehensive Needs Assessment for the purpose of providing services
associated with Care Coordination level 2 or level 3
5. Information about specific next steps for the Member
MAD 754 Revised 3/18/18
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