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September 2016 Volume 8, Issue 9 Chap. 750 MOPH

Page 2

Chapter 750 is Live on eBay. Have anything to donate and we’ll put it on eBay. All we need is an accurate description and digital photos that accurately depict the item. We’ll put anything on eBay if you think it will sell. But you still have to store it until it sells. “Proud to Be an American,” contemporary fine print is our first listing, thanks to Patriot Tony Dean. It is by Camarillo artist J.J. Prescott. See photo below:

Local Services for Veterans Santa Barbara County Veterans Service Officer, Santa Barbara Benefits Assistance Joe Fletcher (805) 681-4500 Veterans Service Officer, Santa Maria Benefits Assistance Rhonda Murphy (805) 346-7160 Veterans Service Office, Lompoc Benefits Assistance Arlyn Sandoval (805) 737-7900 Santa Barbara VA Outpatient Clinic Medical Assistance (805) 683-1491 Santa Maria VA Outpatient Clinic Medical Assistance (805) 354-6000

September 2016 Volume 8, Issue 9 Chap. 750 MOPH

Page 3

Employment Assistance Frank Campo (805) 588-1006 VA HUD-VASH Housing Issues Michael Ulloa (805) 705-0350 Dream Foundation Veterans Dreams Kristy Raihn (888) 437-3267 Congresswoman Capps Wendy Motta (805) 730-1710 Vietnam Veterans Memorial The Moving Wall will be back in Santa Barbara sponsored by Vietnam Veterans of America Chap-ter 218; it will be installed at Chase Palm Park. There are almost 100-names from Santa Barbara County on The Wall. There will be a dedication ceremony Saturday, Oct. 15 at 11am when each of those names will be read and a bell rung. Highlighted by a two fly-overs at the conclusion of the ceremony when four Vietnam era planes (T-34 trainers) including The Missing Man. On Sunday, a candlelight inter-denominational ceremony at 6:30pm to remember all those whose names are on The Wall. The Moving Wall will be open and staffed 24 hours a day. This is the only southern Cal-ifornia stop for The Moving Wall. No Cost Flu Shots Outside the V.A. The V.A. teamed up with Walgreens to allow all veterans in the VA healthcare system to walk into Walgreens and get a vaccination. Available through March 31. You have to present your VA ID card and a photo ID. Locate a participating Walgreens: call 800-925-4733 or use the Internet. Thanksgiving Food Basket Drive Report from David Hieter. The Santa Barbara VA Clinic social worker is working on recipients for the Santa Barbara area. Assembly for these baskets will be at the Hieter house in Goleta on Mon-day November 21st. Jon Williams and Jim Daniels will meet with the Port Hueneme SeaBee Master Chiefs and the SeaBee Museum. We will try to assemble the boxes at the SeaBee Museum on Tuesday November 22nd. Timing is critical as we are dealing with fresh poultry that is not frozen, so we need a maximum effort to get these boxes assembled and delivered in four hours. We seri-ously need volunteers. Call David at (805) 708-2029 or me at 805 565-3759. MOPH January Conference January 18-20 in Clovis. Make hotel reservations quickly. The reservation form is below. Download Veterans Resource Book - California Department of Veterans Affairs goo.gl/iBpg2X Yeah, goo.gl/iBpg2X is real, it’s a Google tool to shorten Website URLs. Veterans Choice Contacts Call 866-606-8198 or goo.gl/mZrmmz, Veterans Choice provides care if you cannot be seen by VA within 30-days or your nearest medical facility is not providing timely access. Veterans are then eli-gible to receive outside care. If you do not have a Choice Card, fill out the VA Form 10-10EZR to update your information or call 1-877-222- 8387. Chapter Meeting Schedule for 2016 Need a ride to the meeting? Contact me. Members may be able to car pool with you. Meetings are generally on the second Thursday of the month at 6:00 pm at the Veterans Home of California, Ventura (805-659-7500). LAMOPH meets same time/same place as the Patriots.

Upcoming Meetings October 13 – November 10 – December 8

Generated by Jive on 2016-05-25-07:001

Virtual Lifetime Electronic Health Record(VLER) and the Veterans Health InformationExchange (VHIE): VLER Health InformationExchange helps Care Coordinator manageVeteran healthcare

Posted by Sabrina Jacobs May 25, 2016

Recently, a VA Maternity Care Coordinator shared how the benefits of using the Veterans Health Information

Exchange (VHIE) which is hosted by the Virtual Lifetime Electronic Health Record (VLER) to receive medical

records in a timely manner, helped her coordinate care for Veteran Patients.

In the first example, a Veteran called to discuss her maternity care and the Maternity Coordinator was able to

view her encounter from the day before at her Community Care Obstetrics (OB) Office. The Coordinator was

able to see her lab results and share them with her within 24 hours of completing them. Care coordination at its

best, as described by the Maternity Care Coordinator!

In another example of an OB patient receiving prenatal care by way of special Letter of Agreement

arrangement with Tri West, the Coordinator was able to view and access her hospital admission and discharge

summary within a few days of her hospital admission. She was then able to communicate to TriWest, who

manages health benefit for Veterans under VA, that the medical documentation was available. When claims

are submitted for payment, payment will be made because the medical documentation has been made

available using VLER.

For more information about the Veterans Health Information Exchange (VHIE) and other programs hosted

by VLER Health, please visit us at www.va.gov/vler. Participating Community Care Partners, who exchange

Health Information with VA, can also be located here.

4 Views Tags: health informatics, vler, connect your docs, obstetrics

VeteranAid.org  

How to Apply for Aid and Attendance  Veterans and their families seeking help in applying for Aid and Attendance pension benefit can use this information about eligibility requirements and application forms.  Eligibility for Aid and Attendance Pension  Any War­Time Veteran with 90 days of active duty, 1 day beginning or ending during a period of War, is eligible to apply for the Aid & Attendance Improved Pension. A surviving spouse (marriage must have ended due to death of veteran) of a War­Time Veteran may also apply. The individual applying must qualify both medically and financially.  To Qualify Medically: 

● A War­Time Veteran or surviving spouse must need the assistance of another person to perform daily tasks, such as eating, dressing, undressing, taking care of the needs of nature, etc. Blind individuals, patients in  a nursing home for mental or physical incapacity, or residents in an assisted living facility also qualify. 

 ● Eligibility must be proven by filing the proper Veterans Application for Pension or 

Compensation.   

● This application will require a copy of DD­214 (see below for more information) or separation papers, Medical Evaluation from a physician, current medical issues, net worth limitations, and net income, along with out­of­pocket Medical Expenses. 

 To Qualify Financially: 

● An applicant must have on average less than $80,000 in assets, EXCLUDING their home and vehicles. 

  The Aid and Attendance Application  

  Step 1: Gather the necessary documents There is much information that needs to be gathered and prepared when applying for the Aid & Attendance Improved Pension. We have compiled a list of the documents you will need, as well as links to download some of the VA and Government Forms that you will need. While it may seem like a daunting task, we recommend that you read 

through this site to better your understanding of the application process so you are prepared before you speak with any Veterans' Affairs Office.  To apply for the Aid & Attendance Improved Pension, you will need the following documents. Prepare these before making your filing.  

● Discharge/Separation Papers (DD­214). If you need to request military records, you can either fill out Standard Form 180 or, you can visitthe National Archives website for further instructions on how to request military records. 

● Copy of Marriage Certificate and all marital information. ● Copy of the Death Certificate (surviving spouses only). ● Copy of current Social Security Award Letter (the letter that Social Security sends at 

the beginning of the year stating what your monthly amount will be for the following year). 

● Net Worth information, including bank accounts, CDs, Trusts, Stocks, Bonds, Annuities, etc. 

● Proof of all income from pensions, retirement, interest income from investments, annuities, etc. 

● If you are a court­appointed guardian of the veteran or surviving spouse, a certified copy of the court order of the appointment is required. 

● Proof of insurance premiums, medications, medical bills or any other medical expenses that are not reimbursed by insurance, Medicare, or Medicaid. 

● Physician statement that includes current diagnosis, medical status, prognosis, name and address, ability to care for self, ability to travel unattended, etc. If you are a veteran in a nursing home, or a family member of a veteran in a nursing home, you can use this form as a certification of that status: Nursing Home Status Statement. 

● Banking information for Direct Deposit of A&A monthly payments (include a voided check). 

● Employment history (does not apply if you are over 65). ● List of all doctors and hospitals visited in the last year. For a list of possible medical 

expenses, click here. For a medical expense report (VA Form 21P­8416), click here.   

Step 2: Complete the necessary VA Form for filing Once you have this information compiled, you will need to obtain and complete VA Form 21­527EZ and/or VA Form 21­534EZ for Special Improved benefits with Aid & Attendance. These forms can be downloaded in PDF format here:  

● VA Form 21­527EZ (For Veterans) ● VA Form 21­534EZ (For Spouses) 

 

Now that you have all your information, follow the instructions on Form 21­527EZ or Form 21­534EZ to file for your Aid & Attendance Improved Pension. If you need assistance with filing your paperwork, you can contact the VA. We encourage you to explore all the available options and services provided through the VA and service agencies to find the option that's right for you and your circumstances.  

 Step 3: Mail the application In mailing your application, we highly recommend that you send your completed application via Certified Mail "Return Receipt" to help avoid the potential of the VA stating that the application was not received. Be certain to keep a copy of the entire application for your own records as well as any other correspondence to and from the VA.  The VA has established various processing center 

across the country that are solely dedicated to processing applications for Improved Pension. When mailing your application, you need to make certain that you send it to the appropriate center assigned for the state where the applicant resides (the applicant is the veteran or spouse). Listed below is the correct mailing address by state:  

AL, AR, IL, IN, KY, LA, MI, MO, MS, OH, TN, WI 

AK, AZ, CA, CO, HI, IA, ID, KS, MN, MT, ND, NE, NM, NV, OK, OR, SD, TX, UT, 

WA, WY  

CT, DC, DE, FL, GA, MA, MD, ME, NC, NH, NJ, NY, PA, PR, RI, SC, VA, VT, WV   

⇩  ⇩  ⇩ 

Milwaukee Pension Maintenance Center 

Veterans Administration 5400 West National Avenue 

Milwaukee, WI 53214  

St. Paul Pension Maintenance Center 

Veterans Administration 1 Federal Drive, Fort Snelling St. Paul, MN 55111­4050 

 

Philadelphia Pension Maintenance Center 

Veterans Administration 5000 Wissahickon Avenue Philadelphia, PA 19144 

 

       

What to Expect after Filing for Aid & Attendance  It is hard to speculate on what you will experience while filing for the Aid & Attendance Pension. Each case is unique and carries its own set of challenges. It will also depend on which processing center will be handling the claim. For unknown reasons, some centers do a more efficient job than others. How complete the application package is will also impact the process.  One thing you can expect is that it will take between 8­10 months on average for your application to be processed and to receive a determination letter. Due to the current backlog of claims to be processed this timeframe can be much longer.  Many families can't afford to pay for care while waiting for the pension to be approved and funds to be released, which places an additional burden. Some Assisted Living Facilities will work with you if they know the resident qualifies for A&A. Fortunately, all benefits are retro­dated back to the original filing date.  If you or your loved one is age 90 or older, you should request the application process be expedited. The VA's own law states that applications for benefits for a veteran/widow age 90 or older are to be given priority. It is advised that you include a cover letter with the application noting this request.  Additional Forms That May Be Needed When Filing  The following forms are not required when filing for Aid & Attendance on your own, but rather may help when you are using outside help to apply for Aid & Attendance.  If you are using a Fiduciary: You can request to be appointed as Fiduciary. The VA does not recognize Power of Attorney (POA) or Durable Power of Attorney (DPOA). Please see our FAQ Section for more detailed information on this subject.  The VA will have to approve the individual who acts as the fiduciary as someone reputable to handle the financial affairs according to their guidelines. This will require a meeting with a Field Agent if you request to be appointed. Due to a lack of Field Agents, the wait time for this meeting to be scheduled can be several months. Be sure to include VA Form 21­0845 (Authorization to Disclose Personal Information to a Third Party), so that you will be able to call the VA on behalf of the claimant. Without this form the VA will not discuss the application with you.  As a special note: The person asking to be appointed as Fiduciary needs to be aware that a felony conviction or a filing of bankruptcy will make you an unacceptable candidate to hold this position. For more information on the fiduciary process, click here.  

 If you are using a service organization:  If you would prefer to have a service organization assist you with your claim, you may use VA Form 21­22: Appointment of Veterans Service Organization As Claimant's Representative.  

● http://www.veteranaid.org/docs/FDC_Surviving_Spouse.pdf ● http://www.veteranaid.org/docs/FDC_VET.pdf ● http://www.veteranaid.org/docs/21­526.pdf 

  If you are still needing assistance, we are here to help! Head on over to our Forums to ask your questions and join the discussions about Aid and Attendance.   

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Rev 06/13

Veterans Home of California (VHC) Admission Application

APPLICATION PREFACE AND GENERAL QUALIFICATIONS

Welcome to the application process, the path to becoming a resident

at one of California’s extraordinary Veterans Homes. We encourage

all eligible veterans to apply for admission. California’s Veterans

Homes are operated as an expression of gratitude toward our State’s

Veterans.

To save time, before you start to fill out the application form, check to see that you meet the basic qualifications for admission. In brief, these qualifications are:

1. You are age 55 or over or, you have a disability. 2. You served in the military and you were honorably discharged. 3. You are still able to live independently or you qualify for a higher level of

care offered at one of the Homes (contact the specific Home for clarification on qualifying for a higher level of care).

4. You are a California resident. 5. You are able to live with and get along with other people in a structured

communal environment. 6. Prior to admission to a Veterans Home, and while a resident at the Home,

veterans must be enrolled in a qualified health insurance plan that covers long-term care, and specialty medical care, including but not limited to:

Medicare Part A

Medicare Part B, Part D

Medi-Cal

TRICARE (including dental) or CHAMPVA

USDVA Health Care

Commercial Insurance (Blue Cross, Blue Shield, etc).

Other health coverage including Long Term Care or comparable insurance

Members not enrolled in a sufficient insurance plan must have an application in process and acknowledge that they will be placed on self-pay status (responsible for all outside medical expenses) until health coverage is obtained. Furthermore members who fail to enroll in Medicare Part B and/or Part D will be responsible for all medical services provided by those coverage’s. Further information about the Homes, photo galleries, and instructions on filling out this application and the admission process can be found online. Go to www.calvet.ca.gov > click on Vet Homes> and select the Home of your choice for information about that Home. Downloadable and printable copies of the Application for the Veterans Home of California are also available.

Rev 06/13

Veterans Home of California (VHC) Admission Application

TABLE OF CONTENTS AND PREFACE If you need help completing this application or have questions, you can call any of the phone numbers listed on page A-4. This application package has three sections. The applicant completes sections A and B and section C is completed by a physician. All responses in each section are required. Section Completed By: Section A: Background Information completed by Applicant

Section B: Authorization for Use and/or Disclosure of completed by Applicant

Resident/Patient Health Information

Section C: Physician’s Medical Certificate completed by Physician

PREFACE

This application should be completed to the best of your ability. It is the first step in gaining residency to a California Veterans Home. CalVet recommends you take the following steps if you wish to expedite the admissions process:

1. Contact your physician as soon as possible and set up an appointment to complete Section C. Note that Section C is valid for 6 months once signed.

2. In addition to filling out and including Section B, use Section B to request the most recent 12 months of medical history from your physician’s office, hospitals, and all other health care providers. Include the documents with your application package. Usually the slowest part of the application process is that the Home must request and wait for your medical records to arrive at the Admissions office. We recommend that you obtain copies of your medical records and send them directly to the Admissions office to avoid delays.

For your application to be considered complete, please submit a copy of the following documents with your application package. A copy of:

Form DD-214, Certificate of Release or Discharge From Active Duty Proof of California Residency, (see page A-1, California Residency) Copies of the front and back side of all your health insurance cards (Medicare, Medi-Cal, TRICARE, USDVA Health Care etc.). Most recent 12 months of medical history

Rev 06/13

Veterans Home of California (VHC) Admission Application

BACKGROUND INFORMATION

Personal Information

Full name ___________________________________________________________________________

Last First Middle

Social Security number _______________________________Date of birth________________________

Driver license number ________________________________State_____________________________

Home address _______________________________________________________________________ Street City State Zip Code

Mailing address (if different from above) __________________________________________________

Home phone ___________________________________Other phone __________________________

Place of birth ___________________________________U.S. citizen? Yes No

If not a U.S. citizen, resident alien number: _________________________________________________

Are you: ___________Male _____________Female

Marital Status Are you currently married? Yes No

If yes, please answer the following questions:

How long have you been married to your current spouse? _________________________________

Is your spouse a veteran? Yes No

Is your spouse also applying for admission to a Veterans Home? Yes No

Spouse’s full name _________________________________________________________________

Last First Middle

____________________________________________________ California Residency Initial here __________ I am a bona fide resident of the State of California. I am submitting a copy of the following proof of my residency (please check one or more).

Valid California Drivers License

California Department of Motor Vehicle Identification Card

Registered Voter Status

Utility Bill that shows the applicant’s residence

Paying California State Income Taxes as a resident

Letter from County Veteran Service Officer or a VA representative

Other: Explain: ______________________________________________

A - 1 of 4

Rev 06/13

Veterans Home of California (VHC) Admission Application

BACKGROUND INFORMATION

Military Service Information What name did you serve under in the military? Full name____________________________________________________________________________

Last First Middle What branch of service were you in? _____________________________________________________ What was your military service number? __________________________________________________ What were your dates of active duty service?

From _______________ until ____________________ Type of discharge ________________ From _______________ until ____________________ Type of discharge ________________

Are you retired from the military? Yes No

Are you the surviving spouse of a Medal of Honor recipient or POW? Yes No

Veterans’ Benefits Information

Have you ever applied for U.S. Department of Veterans Affairs (VA) benefits? Yes No

If yes, what is your VA claim number if known? Claim no.: _______________________________

Do you have any service-connected disabilities? Yes No

If yes, what is the military disability percentage? _____________________________________________

Do you receive non-service-connected pension benefits? Yes No

Do you or your spouse currently have a Cal-Vet loan? Yes No

(Note: On admission, Cal-Vet will be notified.) If yes: Contract no.: _______________________________

Criminal Background Information UPON ACCEPTANCE, YOU MAY BE FINGERPRINTED AND HAVE A CALIFORNIA DEPARTMENT OF JUSTICE CRIMINAL HISTORY SEARCH CONDUCTED

Have you ever had any criminal convictions? Yes No

If yes, provide the following: _____________________________________________________________ Date Type of conviction

_____________________________________________________________ County State

Do you have any criminal charges pending? Yes No

If yes, describe: ______________________________________________________________________

A - 2 of 4

Rev 06/13

Veterans Home of California (VHC) Admission Application

BACKGROUND INFORMATION

Are you currently on probation or parole? Yes No

If yes: ______________________________________________________________________________

Name of probation/parole officer

___________________________________________________________________________________ Address Phone number

___________________________________________________________________________________

County State

Are you required by law to register with local law enforcement? Yes No

Are you currently registered with your local law enforcement as required? Yes No

If yes: ________________________________________________________________________ County State

Medical Information Have you received any medical, psychiatric, alcohol or drug treatment at any medical facility?

Yes No

If yes, which one(s)?

1.__________________________________________________________________________________ Name Address

__________________________________________________________________________________

City/State Zip Code Dates

2.__________________________________________________________________________________ Name Address

__________________________________________________________________________________

City/State Zip Code Dates

3.__________________________________________________________________________________ Name Address

__________________________________________________________________________________

City/State Zip Code Dates

4.__________________________________________________________________________________ Name Address

__________________________________________________________________________________

City/State Zip Code Dates

5.__________________________________________________________________________________ Name Address

__________________________________________________________________________________

City/State Zip Code Dates

A - 3 of 4

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Veterans Home of California (VHC) Admission Application

BACKGROUND INFORMATION

Have you ever applied for admission or lived in any state Veterans Home? If yes, where? ________________________________________________________________________

Name Address City/State Zip Code When? From ____________________________until __________________________________ Comments (add additional sheets if necessary):

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

CalVet offers long-term care in eight Veterans Homes, listed below. Please mark your preference for

which Homes(s) you are interested in applying to. Mark “1” for your first choice, “2” for your second

choice, and so on. If you are not interested in that Home, mark an “X” next to “I do not wish to apply for

this location.” Once your application is accepted and completed at your first choice, that Home will

forward your application package, including medical information, to the other Home(s).

Preference # (Please mark 1 – 8) or “X” If you are not interested in this location

Barstow #_____ or [ ] “I do not wish to apply for this location.”

Chula Vista #_____ or [ ] “I do not wish to apply for this location.”

Fresno #_____ or [ ] “I do not wish to apply for this location.”

Lancaster #_____ or [ ] “I do not wish to apply for this location.”

Redding #_____ or [ ] “I do not wish to apply for this location.”

Ventura #_____ or [ ] “I do not wish to apply for this location.”

West Los Angeles #_____ or [ ] “I do not wish to apply for this location.”

Yountville #_____ or [ ] “I do not wish to apply for this location.”

If you would like help filling out your application or have any questions, we will be happy to answer them:

Barstow 760-252-6281 or Toll Free 800-746-0606 *Fax: 760-252-6379

Chula Vista 619-482-6013 or Toll Free 888-857-2146 *Fax: 619-205-1110

Lancaster 661-974-8141 or Toll Free 888-272-6030 *Fax: 661-974-8198

Ventura 805-659-7502 or Toll Free 888-272-2104 *Fax: 805-659-7559

West Los Angeles 424-832-8202 or Toll Free 877-605-1332 *Fax: 424-832-8205

Yountville 707-944-4601 or Toll Free 800-404-8387 *Fax: 707-948-2525

Redding 530-224-3800 or Toll Free 855-769-5791 *Fax: 530-222-7599

Fresno 559-493-4224 or Toll Free 855-769-5792 *Fax: 559-493-4299

*If faxing your application, it is required to retain the original signatures for submission prior to admission.

______________________________________________________ ___________________ SIGNATURE DATE

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Veterans Home of California (VHC) Admission Application

Authorization for Use and/or Disclosure of Resident/Patient Health Information

Treatment, payment, enrollment, or eligibility for benefits will not be conditioned upon my providing or refusing to provide this authorization. I hereby authorize _____________________________________________________________________

(NAME OF HOSPITAL OR PHYSICIAN YOU ARE REQUESTING RECORDS FROM) ______________________________________________________________________________

(ADDRESS) ______________________________________________________________________________

(CITY) (STATE) (ZIP)

to disclose to ______________________________________________________________________________

(NAME OF VETERANS HOME YOU ARE APPLYING TO)

______________________________________________________________________________ (ADDRESS) ______________________________________________________________________________ (CITY) (STATE) (ZIP)

Records and information pertaining to ______________________________________________________________________________

(NAME OF PATIENT) (MEDICAL RECORD NUMBER) (DATE OF BIRTH)

DURATION: This authorization shall become effective immediately and shall remain in effect until

(Date) ___________or for one year from the date of signature.

REVOCATION: This Authorization is also subject to written revocation by the undersigned at any

time between now and the disclosure of information by the disclosing party. My written revocation will be effective upon receipt, but will not be effective to the extent that the requester or others have relied upon this Authorization.

RE-DISCLOSURE: I understand that the requester may not lawfully further use or disclose the

health information unless another authorization is obtained from me or unless such use of disclosure is specifically required or permitted by law.

B - 1 of 2

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Veterans Home of California (VHC) Admission Application Authorization for Use and/or Disclosure of Resident/Patient Health Information

SPECIFY RECORDS: Check the box(es) and initial to specify the type of information to be

disclosed

MEDICAL INFORMATION ___________ (specify below) INITIAL

PSYCHIATRIC INFORMATION [Cal. Wel. & Inst. Code 5328] ___________________________________________________ _____________________

SIGNATURE DATE

DRUG/ALCOHOL INFORMATION [42 C.F.R. 2.11 & 2.12]

___________________________________________________ _____________________

SIGNATURE DATE

RESULTS OF AN HIV BLOOD TEST (Health and Safety code section 121020) ___________________________________________________ _____________________

SIGNATURE DATE

OTHER INFORMATION ___________ (specify below) INITIAL Specify the records to be disclosed: _______________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ The requester may use the health information authorized on this form for medical screening purposes

only as outlined in Section C as part of their application for admission to a California Veterans Home. A

copy of this authorization will be given to the requestor.

Signature: __________________________________________ Date: / / . If signed by other than resident/patient, indicate relationship: ___________________________________ [Ref. 45 C.F.R. 164.508; Cal Civil Code 56.11]

B - 2 of 2

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Veterans Home of California (VHC) Admission Application

Physician’s Medical Certificate

This section to be completed by a physician and is designed to assess the resource needs for health care of the patient.

THIS CERTIFICATION IS VALID FOR SIX MONTHS. ALL INFORMATION MUST BE

CURRENT AND COMPLETE TO AVOID DELAYS IN PROCESSING YOUR

PATIENT’S APPLICATION

Rev 06/13

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

PHYSICIAN'S REPORT FOR ADMISSION

I. FACILTY INFORMATION (To be completed by the licensee/designee)

1. NAME

2. TELEPHONE ( )

3. ADDRESS CITY ZIP CODE

4. LICENSEE’S NAME 5. TELEPHONE 6. FACILITY LICENSE NUMBER

ll. RESIDENT/PATIENT INFORMATION To be completed by the resident/resident’s responsible person)

1. NAME 2. BIRTH DATE 3. AGE

III. AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION (To be completed by resident/resident’s legal representative)

I hereby authorize release of medical information in this report to the facility named above

1. SIGNATURE OF RESIDENT AND/OR RESIDENT’S LEGAL REPRESENTATION

2. ADDRESS 3. DATE

IV. PATIENT’S DIAGNOSIS (To be completed by physician)

NOTE TO PHYSICIAN: The person named above is either a resident or prospective resident of one of six (6) California Veterans Homes. The information that you provide about this person is required by law to assist in determining whether the person is appropriate for care in one or more of these facilities. It is important that all questions be answered.

(Please attach separate pages if needed.) 1. DATE OF EXAM 2. SEX 3. HEIGHT 4. WEIGHT 5. BLOOD PRESSURE

6. TUBERCULOSIS (TB) TEST

a. Date TB Test Given

b. Date TB Test Read c. Type of TB Test d. Please Check if TB Test is: Negative Positive

e. Results: mm _____________ f. Action Taken (if positive): ________________________________ ________________________________________________________________________________ g. Chest X-ray Results: ________________________________________________________________ h. Please Check One of the Following:

Active TB Disease Latent TB Infection No Evidence of TB Infection or

Disease LIC 602A (12/04) (CONFIDENTIAL) PAGE 1 OF 6

Rev 06/13

PRIMARY DIAGNOSIS: a. Treatment/medication (type and dosage)/equipment:

b. Can patient manage own treatment/medication/equipment? Yes No

c. If not, what type of medical supervision is needed?

8. SECONDARY DIAGNOSIS(ES): a. Treatment/medication (type and dosage)/equipment:

b. Can patient manage own treatment/medication/equipment? Yes No

c. If not, what type of medical supervision is needed?

9. CHECK IF APPLICABLE TO 7 OR 8 ABOVE:

Mild Cognitive Impairment: Refers to people whose cognitive abilities are in a “conditional state”

between normal aging and dementia.

Dementia: The loss of intellectual function (such as thinking, remembering, reasoning, exercising

judgement and making decisions) and other cognitive functions, sufficient to interfere with an individual’s ability to perform activities of daily living or to carry out social or occupational activities.

10. CONTAGIOUS/INFECTIOUS DISEASE:

a. Treatment/medication (type and dosage)/equipment:

b. Can patient manage own treatment/medication/equipment? Yes No

c. If not, what type of medical supervision is needed?

LIC 602A (12/04) (CONFIDENTIAL) PAGE 2 OF 6

Rev 06/13

11. ALLERGIES: a. Treatment/medication (type and dosage)/equipment:

b. Can patient manage own treatment/medication/equipment? Yes No

c. If not, what type of medical supervision is needed?

12. OTHER CONDITIONS:

a. Treatment/medication (type and dosage)/equipment:

b. Can patient manage own treatment/medication/equipment? Yes No

c. If not, what type of medical supervision is needed?

13. PHYSICAL HEALTH STATUS

YES NO ASSISTIVE DEVICE

(If applicable) EXPLAIN

a. Auditory Impairment

b. Visual Impairment

c. Wears Dentures

d. Wears Prosthesis

e. Special Diet

f. Substance Abuse Problem

g. Use of Alcohol

h. Use of Cigarettes

i. Bowel Impairment

j. Bladder Impairment

k. Motor Impairment/Paralysis

l. Requires Continuous

Bed Care

m. m. History of Skin Condition or

Breakdown

LIC 602A (12/04) (CONFIDENTIAL) PAGE 3 OF 6

Rev 06/13

14. MENTAL CONDITION YES NO EXPLAIN a. Confused/Disoriented

b. Inappropriate Behavior

c. Aggressive Behavior

d. Wandering Behavior

e. Sundowning Behavior

f. Able to Follow Instructions

g. Depressed

h. Suicidal/Self-Abuse

i. Able to Communicate Needs

j. At Risk if Allowed Direct

Access to Personal

Grooming and Hygiene Items

k. Able to Leave Facility

Unassisted

15. CAPACITY FOR SELF-CARE YES NO EXPLAIN

a. Able to Bathe Self

b. Able to Dress/Groom Self

c. Able to Feed Self

d. Able to Care for Own

Toileting Needs

e. Able to Manage Own

Cash Resources

16. MEDICATION MANAGEMENT YES NO EXPLAIN

a. Able to Administer Own

Prescription Medications

b. Able to Administer Own

Injections

c. Able to Perform Own

Glucose Testing

d. Able to Administer Own

PRN Medications

e. Able to Administer Own Oxygen

f. Able to Store Own Medications

LIC 602A (12/04) (CONFIDENTIAL) PAGE 4 OF 6

Rev 06/13

17. AMBULATORY STATUS:

a. This person is considered: Ambulatory Nonambulatory Bedridden

Nonambulatory: Means persons unable to leave a building unassisted under emergency conditions. It includes any person who is unable, or likely to be unable, to physically and mentally respond to a sensory signal approved by the State Fire Marshal, or to an oral instruction relating to fire danger, and persons who depend upon mechanical aids such as crutches, walkers, and wheelchairs. (Health & Safety Code Section 13131)

Bedridden: Means either requiring assistance in turning and repositioning in bed, or being unable to independently transfer to and from bed, except in facilities with appropriate and sufficient care staff, mechanical devices if necessary, and safety precautions. No resident shall be admitted or retained in a residential care facility for the elderly if the resident is bedridden, other than for a temporary illness

or for recovery from surgery. (Health & Safety Code Section 1569.72)

b. If resident is nonambulatory, this status is based upon:

Physical Condition Mental Condition Both Physical and Mental Condition

c. Ia c. If a resident is bedridden, check one or more of the following and describe the nature of the illness, surgery or other cause:

Illness: _______________________________________________________________________

Recovery from Surgery: _________________________________________________________

Other: _______________________________________________________________________

NOTE: An illness or recovery is considered temporary if it will last 14 days or less.

d. If a resident is bedridden, how long is bedridden status expected to persist?

1. _________________(number of days)

2. __________________________(estimated date illness or recovery is expected to end or when resident will no longer be confined to bed)

3. If illness or recovery is permanent, please

explain:_____________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

e. Is resident receiving hospice care?

No Yes If yes, specify the terminal illness: ________________________________

LIC 602A (12/04) (CONFIDENTIAL) PAGE 5 OF 6

Rev 06/13

18. PHYSICAL HEALTH STATUS: Good Fair Poor

19. COMMENTS:

20. PHYSICIAN'S NAME AND ADDRESS (PRINT)

21. TELEPHONE

22. LENGTH OF TIME RESIDENT HAS BEEN YOUR PATIENT

23. PHYSICIAN'S SIGNATURE

24. DATE

LIC 602A (12/04) (CONFIDENTIAL) PAGE 6 OF 6