IT OPerations manual



|*INDIVIDUAL’S NAME: |Janie Doe |*ID NUMBER: |000000000 |

|Member Information and Background |

|*1. | Date of Birth (mm/dd/yyyy): |00/00/0000 |

| |Date of Evaluation (mm/dd/yyyy): |01/30/2014 |

|2. | | |

|*3. | Address Line 1: |Superior Rehab Nursing Facility |

| | Address Line 2: |000 Main Street |

| | City: |Anytown | State: |CT | Zip Code: |00000 |

|*4. |Evaluation Location Address L1: |Superior Rehab Nursing Facility |

| |Evaluation Location Address L 2: |000 Main Street |

| |Evaluation City: |Anytown |Evaluation State: |CT |Evaluation Zip Code: |00000 |

| 5. | Height: |5 |FT |5 |

| | |Mary Otherapist |MS, OTR |Superior Rehab Nursing Facility |

| | |Jane Wondernurse |RN |Superior Rehab Nursing Facility |

| | |      |      |      |

| | |      |      |      |

|*7. |DME Provider Evaluator: |Jay Doe |ATP |ABC Wheelchair Company |

| 8. | Not Required for SNF/ICF Residents |

| |Caregiver/Family: |      |Present During Evaluation? |      |

| *9. |Prescribing Physician: |Johnney A. Doe, MD |

| *10.|Physician Phone Number: |000-000-0000 |

|*11. |Physician Agency: |Internal Medicine Specialists, Inc |

| |Physician Address: |00000 Main Street |

| |Physician City: |Anytown |Physician State: |CT |Physician Zip Code: |000000 |

| 12. |a. Primary | |Initial Wheeled Mobility Device |b. Primary Issues | |Size |

| |Reason for | | |Relating to DME | | |

| |Evaluation: | | |(explain in 12c): | | |

| | | |Replacement | | |Does not address current medical needs |

| | | |Modification/Repairs | | |Does not address current functional needs |

| |c. Other Pertinent Information; i.e., |N/A |

| |additional information from 12b, | |

| |rationale for replacement vs. | |

| |modification, repair history, other | |

| |information regarding request: | |

|13. |General Description of |Invacare Solara 3G Tilt-in-Space wheelchair with Matrx PB Contoured back and High Profile ROHO seat |

| |DME Recommendation: |cushion |

| | | |

|*INDIVIDUAL’S NAME: |Janie Doe |*ID NUMBER: |000000000 |

|14. |DIAGNOSIS(ES), INCLUDING RECENT SURGERIES AND DATES OF SURGERIES |RECENT CHANGE IN |

| | |MEDICAL STATUS |

| |Right CVA with resulting Left hemiplegia, apraxia, and left side visual neglect (8/15/13) |YES |NO |NA |

| | |see 14a | | |

| | | | | |

| |Left CVA and MCA with resulting expressive aphasia (2009) |YES |NO |NA |

| | |see 14a | | |

| | | | | |

| |Hx of Hypertension, DM II, alcoholism, IV drug abuse |YES |NO |NA |

| | |see 14a | | |

| | | | | |

| |      |YES |NO |NA |

| | |see 14a | | |

| | | | | |

| |      |YES |NO |NA |

| | |see 14a | | |

| | | | | |

|14a. |Explain recent change in medical |Previously living at home before Right CVA; transferred from the hospital on 8/21/13 |

| |condition and/or other relevant | |

| |information including symptoms, |Baclofen pump insertion 4/15/2013 since oral medication ineffective to address spasticity and associated pain |

| |treatments, interventions and |(see physician's note 4/01/2013) |

| |medications: | |

|15. |How will the person’s | The requested Wheeled Mobility Device can be modified to meet anticipated medical needs. |

| |anticipated medical changes be | |

| |accommodated in the requested | |

| |Wheeled Mobility Device? | |

| | | Other |

| | |The specified wheelchair frame can be modified since it is a modular frame. The seating components can be |

| | |modified or additions can be made if/when the patient's medical status changes or to address wear and tear |

| | |issues. |

| | | |

| | | |

16. Caretaker Support: The individual has 24 Hour Care.

|16a. |

|*INDIVIDUAL’S NAME: |Janie Doe |*ID NUMBER: |000000000 |

*18. List all Current/Previous DME:

|DME TYPE, INCLUDING MANUFACTURER |DATE|ENVIRONMENTS |IS DME|IF |SKILL LEVEL | |18A. |

|AND MODEL |OF |WHERE USED |CURREN|INEFFEC|(CHECK ALL THAT APPLY) | | |

| |PURC|(SELECT ALL |TLY |TIVE, | | | |

| |HASE|THAT APPLY) |BEING |PROVIDE| | | |

| |(MM/| |USED? |REASON | | | |

| |YY) | | | | | | |

| | |School | |N/A | | |Below normal endurance and distance |

| | |Community | | | |Dependent |

| | |SNF/ICF | | | |Other:       |

|Comments, including |      |

|special features (e.g., | |

|specialty seating | |

|components or | |

|electronics): | |

|Ownership: | |Personally Owned | |Other       |

|18B. |whee|>? 5 yrs old | |Home | |YES |sizing is incorrect; unable to provide adequate|

| |lcha| | | | | |support since it lacks tilt-in-space feature |

| |ir | | | | | | |

| | |School | |N/A | | |Below normal endurance and distance |

| | |Community | | | |Dependent |

| | |SNF/ICF | | | |Other:       |

|Comments, including |This therapist added seating components; however, frame modifications are not permitted by the nursing facility and the seating |

|special features (e.g., |additions are inadequate to address her seating needs. It is not possible to address Ms. Simmon's postural needs in this |

|specialty seating |wheelchair since she is unable to attain or sustain her trunk and head position without the assistance of gravity. A |

|components or |Geri-Recliner was trialed but was ineffective due to hamstring ROM musculature deficits. |

|electronics): | |

|Ownership: | |Personally Owned | |Other This wheelchair is owned by the nursing facility. |

|18C. |show|2010 | |Home | |YES |effective; used by many residents |

| |er | | | | | | |

| |chai| | | | | | |

| |r | | | | | | |

| | |School | |N/A | | |Below normal endurance and distance |

| | |Community | | | |Dependent |

| | |SNF/ICF | | | |Other:       |

|Comments, including |      |

|special features (e.g., | |

|specialty seating | |

|components or | |

|electronics): | |

|Ownership: | |Personally Owned | |Other This shower chair is owned by the nursing faciity. |

|18D. |    |      | |Home | |YES |      |

| |  | | | | | | |

| | |School | |N/A | | |Below normal endurance and distance |

| | |Community | | | |Dependent |

| | |SNF/ICF | | | |Other:       |

|Comments, including |      |

|special features (e.g., | |

|specialty seating | |

|components or | |

|electronics): | |

| | |

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|Ownership: | |Personally Owned | |Other       |

|*INDIVIDUAL’S NAME: |Janie Doe |*ID NUMBER: |000000000 |

19. Functional Skills

|ACTIVITY |LEVEL OF INDEPENDENCE |DME USED TO ADDRESS FUNCTIONAL |COMMMENTS/FUNCTIONAL CONSIDERATIONS |

| | |TASK |FOR REQUESTED DME: |

|Bathing | |Independent | |Mod Assistance |Provide number from DME|18c |requires head and trunk postural components in tilted |

| | | | | |list on page 3: | |shower chair |

| | |Supervision | |Max Assistance | | | |

| | |Min Assistance | |Dependent | | | |

|Dressing | |Independent | |Mod Assistance |Provide number from DME|      |      |

| | | | | |list on page 3: | | |

| | |Supervision | |Max Assistance | | | |

| | |Min Assistance | |Dependent | | | |

|Grooming | |Independent | |Mod Assistance |Provide number from DME|      |      |

| | | | | |list on page 3: | | |

| | |Supervision | |Max Assistance | | | |

| | |Min Assistance | |Dependent | | | |

|Eating | |Independent | |Mod Assistance |Provide number from DME|18b |G-Tube feedings; aspiration risks and precautions |

| | | | | |list on page 3: | |taken; in process of obtaining dysphagia assessment |

| | | | | | | |for possible oral feeding |

| | |Supervision | |Max Assistance | | | |

| | |Min Assistance | |Dependent | | | |

|Toileting | |Independent | |Mod Assistance |Provide number from DME|      |      |

| | | | | |list on page 3: | | |

| | |Supervision | |Max Assistance | | | |

| | |Min Assistance | |Dependent | | | |

|In-home | |Independent | |Mod Assistance |Provide number from DME|18b |see comments 18b |

|mobility | | | | |list on page 3: | | |

| | |Supervision | |Max Assistance | | | |

| | |Min Assistance | |Dependent | | | |

20. Orthosis(es)/Prosthesis(es): NA / None

|ITEM |LEFT |RIGHT |BOTH |EFFEC|COMMENTS/IF | |

| | | | |TIVEN|INEFFECTIVE, | |

| | | | |ESS |PLEASE EXPLAIN | |

| | | | | |Ineffective | |

| | | | | |NA / None | |

|Knee-Ankle-Foot | | | | |Effective |      |

|Orthosis(es) | | | | | | |

| | | | | |Ineffective | |

| | | | | |NA / None | |

|Below Knee | | | | |Effective |      |

|Prosthesis(es) | | | | | | |

| | | | | |Ineffective | |

| | | | | |NA / None | |

|Above Knee | | | | |Effective |      |

|Prosthesis(es) | | | | | | |

| | | | | |Ineffective | |

| | | | | |NA / None | |

|TLSO |N/A | |Effective |      |

| | | |Ineffective | |

| | | |NA / None | |

|LSO |N/A | |Effective |      |

| | | |Ineffective | |

| | | |NA / None | |

|Other: | | | | |Effective |      |

|      | | | | | | |

| | | | | |Ineffective | |

| | | | | |NA / None | |

|*INDIVIDUAL’S NAME: |Janie Doe |*ID NUMBER: |000000000 |

21. Transfer skills: Independent for all transfers Dependent for all transfers Varied transfer skills; see completed table

|FROM |

|*INDIVIDUAL’S NAME: |Janie Doe |*ID NUMBER: |000000000 |

24. Postural Control, Muscle Strength, and tone (Medical Research Council [MRC] Scale for Muscle Strength)

|STRENGTH |( + )| |( + ) / ( |TON|COMMENTS | |

| |/ ( -| |- ) |E | | |

| |) | | | | | |

|Right Upper | |WNL (5) |(     ) | |Trace (1) |(     ) |

|Extremity: | | | | | | |

|Left Upper | |WNL (5) |(     ) | |Trace (1) |(     ) |

|Extremity: | | | | | | |

|Right Lower | |WNL (5) |(     ) | |Trace (1) |(     ) |

|Extremity: | | | | | | |

|Left Lower | |WNL (5) |(     ) | |Trace (1) |(     ) |

|Extremity: | | | | | | |

|Head/Neck: | |WNL (5) |(     ) | |Trace (1) |(     ) |

25. Postural Alignment of trunk, pelvis, neck, and lower extremities

| |POSTURAL ALIGNMENT |FIXED VS. FLEXIBLE |COMMENTS, INCLUDING QUANTITATIVE |

| | | |DATA |

|Trunk/Spine: | |Alignment WNL | |Lordosis | |

|Pelvis/Hips: | |Even | |Pelvic | |

| | | | |Obliquity Lower| |

| | | | |on Right | |

|Ankles/ | |

|Foot/Toes: | |

|*INDIVIDUAL’S NAME: |Janie Doe |*ID NUMBER: |000000000 |

26. Coordination, Motor Control, and Balance

|ACTIVITY |FUNCTIONAL SKILLS |ACTIVITY |COMMENTS/FUNCTIONAL SKILLS |

|Sitting | |Steady, safe |Standing | |Functional |

|Balance | | |(Static): | | |

|(Static): | | | | | |

| | |Leans or slides | | |Unsteady |

| | |Unable | | |Steady, but uses wide stance and/or uses support |

| |Other:| | | | |

| | |Other: leans to left side | | |Narrow stance without support |

| | | | | |Unable Other: requires 2 persons w/ L knee block |

|Upper | |Functional |Upper | |Functional |

|Extremity | | |Extremity | | |

|Gross Motor | | |Fine Motor | | |

|Control: | | |Control: | | |

| | |Mild/moderate impairment | | |Mild/moderate impairment |

| | |Dependent | | |Dependent |

| | |Other:       | | |Other:       |

27. Range of Motion (Optional – attach data)

|AREA AFFECTED |RANGE OF MOTION LIMITATIONS RELATIVE TO SEATING |COMMENTS/QUALIFYING INFORMATION |

|Right Upper Extremity: |-10 degrees elbow extension |pain with PROM (see attached ROM chart) |

|Left Upper Extremity: |-25 degrees elbow extension; -20 wrist extension |pain with PROM (see attached ROM chart) |

|Right Lower Extremity: |-10 degrees knee extension |pain with PROM (see attached ROM chart) |

|Left Lower Extremity: |-25 degrees knee extension; -30 degrees hip extension |pain with PROM (see attached ROM chart) |

|Head/Neck: |WNL; tightness at end range in all planes |pain with PROM (see attached ROM chart) |

28. Pain (Ref: SOPResources/ClinicalTools/government-websites/). Unable to determine if person is experiencing pain

|LOCATION |INTENSITY |FREQUENCY |DURATION |COMMENTS/QUALIFYING INFORMATION; |

| | | | |RELATIONSHIP TO POSITIONING |

| | None | |

| |Intact | |Intact | |None |

| |Impaired | |Impaired | |Impaired Nutritional Status |

|If Impaired, date(s) of onset: |      |If Impaired, date(s) of onset: |9/2013 | |Bony Prominences |

|If Impaired, stage: |      |If Impaired, stage: |2 | |Fecal and/or Urinary Incontinence |

|If Impaired, location(s): |      |If Impaired, location(s): |coccyx | |Circulatory Compromise |

|Ability to use pressure reducing methods: | |Self-Positioning | |Immobility |

|attempts to shift weight but is unsuccessful | | | | |

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| | |Decreased Self-Positioning Skills | |Sensory Deficits |

| | |Non Self-Positioning | |Aged Skin |

| | |Other |If Sensory Deficits, indicate: |

|General Comments:       |lacks light touch sensation L LE and L UE |

| |responds to deep pressure |

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|*INDIVIDUAL’S NAME: |Janie Doe |*ID NUMBER: |000000000 |

30. Cardiovascular, Pulmonary, Vascular, Bowel and Bladder status

| |CONDITION |CLINICAL OBSERVATIONS / REFERENCE TO DIAGNOSIS |

|Cardiac Status: | |Normal |see diagnoses #14 |

| | |Impaired | |

| | |Unable to Determine Status | |

| | |      | |

|Pulmonary Status: | |Normal |      |

| | |Impaired | |

| | |Lack of Clinical Evidence to Determine Status | |

| | |      | |

|Vascular Status: | |Normal |discoloration noted B LEs below mid-calves which |

| | | |improves with tilted wheelchair |

| | |Impaired | |

|If Impaired, | |1+ Barely detectible impression when finger pressed into skin |improves with pillow under calves when in bed and with|

|Edema | | |tilted wheelchair |

|Grade Level: | | | |

| | |2+ Slight indentation: 15 seconds to rebound | |

| | |3+ Deeper indentation: 30 seconds to rebound | |

| | |4+ >30 seconds to rebound | |

|Bowel and | |Continent Bowel and Bladder |      |

|Bladder Status: | | | |

| | |Incontinent Bowel and Bladder | |

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|Catheterization: |

32. Describe the effectiveness of the trial simulation(s), including the person’s ability to utilize the recommended wheeled mobility device system within their customary environment(s), i.e., hallways, bedroom, bathroom, ramp, varied terrain. The following criteria/ information must be included reflecting the person’s cognitive, visual, safety, and fine and gross motor skills: (1) strength (2) endurance (3) range of motion (4) balance (5) risk factors considered, e.g., repetitive motion (6) location of trials (7) duration/frequency of trial(s) (8) ability to use controls; e.g., directionality, start/stop, special features; i.e., tilt, recline, power leg rests, seat elevator, power assist, one arm drive, tiller (9) need for additional training or caretaker assistance for drive controls. Indicate Dependent if applicable.

|Ms. Doe will be dependent using the requested manaul wheelchair. |

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33. Are there anticipated changes in the individual’s customary environments with the next 1-2 years? If so, how was this taken into consideration for the requested wheeled mobility device?

No Yes, please explain:

|The long term goal is for Ms. Doe to return home; however, the family is currently unwilling to consider this option. At that time, Money Follows the |

|Person program will be considered. Although a power chair was considered and trialed, Ms. Doe lacks adequate cogntive and visual perceptual skills for |

|effective and safe power chair use; i.e., severe left visual neglect, cognitive deficits, and lack of safety sense. If her visual perceptual, visual motor|

|and cogntive status improves, a power chair will be re-evaluated. |

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|*INDIVIDUAL’S NAME: |Janie Doe |*ID NUMBER: |000000000 |

34. Explain/describe other medical approaches, functional strategies, other DME and/or alternative treatment(s), which were considered and ruled out in lieu of using a wheeled mobility device.

|See #18a & #33 regarding rollator ineffectiveness and results of power chair trial. In addition, the neurological evaluation 10/2013 (attached) reveal |

|severe diffuse cerebral damage. |

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35. For residents of Skilled Nursing Facilities:

|What is the length of |During the trial of loaner tilt-in-space wheelchair, Ms. Doe was able to tolerate wheelchair positioning ~9 hours per |

|time per day that the wheeled |day (3 hours x3 daily), including each meal. |

|mobility | |

|device will be used? | |

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|If this request is for a replacement wheeled mobility device under Sec. 17-134d-46 Customized Wheelchairs In Nursing Facilities Regulation, attach a copy |

|of the current positioning program (required). |

|Describe the positioning program |This is not for a replacement wheelchair. She is rotated side-to-side in bed. |

|used to | |

|address the individual’s | |

|needs, including the | |

|monitoring program. | |

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|What is the person’s |2-4 hrs/daily: She is currently out of bed for 2 meals daily (lunch and dinner), and in bed other times with a pillow |

|out of bed tolerance? |under calves. Based upon her facial grimaces, she appears to be uncomfortable after 1-2 hours in an upright wheelchair.|

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36. Training to be provided to who/where/by whom for wheeled mobility use:

|CLINICAL OBSERVATIONS / REFERENCE TO DIAGNOSIS |

| |Request is for replacement Wheeled Mobility Device; therefore, the member has demonstrated proficient wheeled mobility skills |

| |PT/OT Training |

| |N/A: Individual is fully independent |

| |Other, please explain |

|Training will be provided by the evaluating OT to nursing staff regarding appropriate positioning in requested wheelchair, including medical precautions |

|and associated clinical symptoms, and alternative positioning options. Based upon the results of the dysphagia evaluation, recommendations and training |

|regarding neck position to be emphasized. |

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37. Comments (include e. g., Continued from #xx):

|N/A |

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|*INDIVIDUAL’S NAME: |Janie Doe |*ID NUMBER: |000000000 |

Based on the clinical assessment and consideration of various Wheeled Mobility options, the following is suggested to address this person’s medical needs:

|38. |* Description of DME component: |39. Medical Rationale: Pre-populated, generic, and general rationales and definitions will |

| |This list can be pre-populated by the DME|not be accepted. Information must include: |

| |Provider. Postural components can be |Document the rationale for requested base or component for this specific person, as correlated with the |

| |combined with hardware; e.g., lateral |documented clinical information. Reference comparisons and simulations; e.g., “Based upon trials of the |

| |trunk pads with swing-away mounting |seat cushions xx, yy, and zz, the zz cushion was chosen because….” Note: Only the essential components |

| |hardware; phenolic upper extremity |require comparison of various options, as related to the person’s medical condition. |

| |support with channel locks and strap. |If appropriate, include reason why a standard component would not address the person’s medical needs. |

| | | * |Technical rationales can be written by the DME provider which should be designated with an |

| | | |asterisk. Include the reason the component is needed, as compared to less complex alternatives |

| | | |and correlated with necessary functional or technical outcomes. |

|a. |*Solara 3G Tilt in Space (TS) wheelchair |She is unable to attain/sustain her trunk/head position without gravity assistance. A Geri-Recliner & |

| | |upright wheelchair were trialed but were ineffective. Tilt-in-space (TS) is needed since for pressure |

| | |relief and inhibit loss of skin integrity, and to maximize her sitting endurance/tolerance. Her neck |

| | |position can be controlled in TS to inhibit aspiration risks. IRIS TS wheelchair seat height is too high |

| | |for long-term Tx objective to increase transfer skills. |

|b. |*flat free tires |to maintain tire air pressure for safe transfers |

|c. |*seat pan |*Flush drop style seat plan chosen to decrease seat height without frame modifications which is the |

| | |primary reason for choosing this wheelchair frame as compared to IRIS. Lower seat height needed to |

| | |increase transfer skills. Base will support ROHO seat cushion. |

|d. |*full length adjustable armrests |for B UE weight bearing to optimize her trunk/neck control |

|e. |*push button 2" pelvic positioner |for pelvic stability and safety |

|f. |*Elevating legrests (ELRs) with |ELRs aim to gradually increase LE ROM associated with ROM deficits in knees/hips as per B hamstring |

| |adjustable footplates; heel loops; |musculature hypertonia. Medial footblocks with heel loops provide placement cue for proper foot |

| |padding on hangers; medial footblocks, |alignment. Padded hangers will protect skin due to sensory deficits. Footplate extensions needed to |

| |calf panel; footplate extensions |accommodate foot length. Custom calf panel needed to provide contoured & full weight bearing since she is|

| | |intolerant of std flat pads with apparent pain. |

|g. |*Matrix PB back with mounting hardware |-to provide posterior/ lateral contoured weight bearing and maximize weight bearing to increase sitting |

| | |tolerance/endurance |

| | |-to inhibit lateral thoracic trunk leaning |

| | |-Planar/linear back was evaluated and found ineffective due to shape of body contact surface |

| | |-Jay3 contoured back too shallow to accommodate kyphotic posture |

|*INDIVIDUAL’S NAME: |Janie Doe |*ID NUMBER: |000000000 |

|h. |*High Profile ROHO seat cushion with |-to offer high level of skin protection and comfort and sitting tolerance |

| |heavy duty, fluid resistant cover |-to decrease likelihood loss of skin integrity due to documented risks |

| | |-fluid resistant cover offer enhanced protection due to incontinence |

| | |-Jay3 and ZeroG cushions trialed- found to be ineffective since posterior pelvic tilt increased |

|i. |*Hip guides with L-bracket hardware |-to provide lateral pelvic guides to center her hips within the seating system to impede lateral trunk |

| | |leaning/pelvic assymetry |

| | |-brackets needed to attach to seat pan |

|j. |*Half tray with elbow blocks, tray |-for L UE weight bearing to maximize trunk alignment and decrease lateral/rotary tendencies |

| |hardware |-lateral and posterior elbow blocks are needed to prevent L UE from falling off tray when in tilted |

| | |position and to also align UEs with shoulder girdle |

|k. |*14' Plush headrest with LINX hardware |-to provide posterior head support due to poor neck/head control |

| | |-to decrease aspiration risks |

| | |-hardware mounts headrest to Matrx back support |

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|*INDIVIDUAL’S NAME: |Janie Doe |*ID NUMBER: |000000000 |

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|x. |      |      |

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|z. |      |      |

|aa. |      |      |

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|*INDIVIDUAL’S NAME: |Janie Doe |*ID NUMBER: |000000000 |

|bb. |      |      |

|cc. |      |      |

|dd. |      |      |

|I certify that I wrote this report and I am the Licensed Occupational and/or Physical Therapist identified below. I have included my credentials, |

|affiliated agency, address, and contact information.  My signature affirms that I personally wrote each section of this report, except where an asterisk is|

|designated, based upon my own clinical knowledge, training and evaluation of the person’s medical condition. |

|Name: |Mary Otherapist |Credentials: |MS, OTR |CT License #: |00000 |

|Agency: |Superior Rehab Nursing Facility |

|Address L1: |000 Main Street |

|Address L2: |      |

|City: |Anytown |State: |CT |Zip Code: |00000 |

|Phone Number: |000-000-0000 |Fax Number: |0000000000 |Email |mortherapist@ |

| | | | |Address: | |

| |

|Electronic Signature Agreement. By clicking “I agree” and electronically signing below, you certify that: (1) you and the agency/facility in which you are |

|employed agree to follow and are in compliance with the Connecticut Department of Social Services Conditions for DSS Acceptance of Electronic Signatures |

|(“Electronic Signature Policy”) and (2) your electronic signature below complies with the Electronic Signature Policy.  A handwritten signature is required|

|for all other practitioners. |

| |Signature: |Mary Otherapist, MS, OTR |Date (mm/dd/yyyy): |02/15/2014 |

|Physician’s Signature: By signing below, I have reviewed and concur with the above evaluation: |

|Physician Agency: |Internal Medicine Specialists, Inc |

|Physician NPI: |000000000 |

|Electronic Signature Agreement. By clicking “I agree” and electronically signing below, you certify that: (1) you and the agency/facility in which you are |

|employed agree to follow and are in compliance with the Connecticut Department of Social Services Conditions for DSS Acceptance of Electronic Signatures |

|(“Electronic Signature Policy”) and (2) your electronic signature below complies with the Electronic Signature Policy.  A handwritten signature is required|

|for all other practitioners. |

|Signature: |Johnnie A Doe, MD |Date (mm/dd/yyyy): |02/17/2014 |

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