Form HCSP-M11Q Medical Request for Home Care - New York City

Form HCSP-M11Q Application Instructions

Instructions for the HCSP-M11Q Application are the following:

1. Client's information such as their name, address, date of birth, and Social Security number should be indicated.

2. The date and place of the medical examination should be entered.

   • Current condition. Indicate diagnoses of the patient and check prognosis regarding each one.
   • Hospital information. The hospital name, admission date, and reason for hospitalization should be entered.
   • Medication. This part contains information about the medication taken, including dosage and frequency, the ability of the patient to take them on their own. If the patient needs help in taking medication, the physician should answer additional questions concerning it.
   • Medical treatment. The filer should check the medical treatment received by the patient from the list provided in the table. It is necessary to describe below a recommended frequency of treatment indicated, and how this service has been provided.

3. The physician should give recommendations in assistance with personal care, including the reasons for such recommendations. If in their opinion, the patient is not able to direct a home care worker, the medical professional should explain why.

   • Equipment/Supplies. The filer should check the equipment the patient has, needs and has been ordered from the list below. If some needed equipment was not ordered, the physician should explain the reasons.
   • Referrals. The medical professional should provide information about the home care agencies to which the request was forwarded.
   • Additional Comments. It is required to describe other aspects of the patient's medical and social situation which affect the need for home care.

4. Physician's Certification.

   • The medical professional should print their name, specialty, and business address.
   • The date of completing the form, the registry number, NPI (national provider ID), the telephone number, and email of the physician should be provided. The medical professional should sign the form within 30 days after the date of the examination.
   • Indicate the hospital where the form was filled in, including its address, and information about a nurse or social worker who has helped in completing the form.

Where to Send Form HCSP-M11Q?

The completed signed M11Q Form should be sent within 30 calendar days after the medical examination to the following address: NYC HRA Home Care Services Program, Central Intake, 132 W. 125th St.,5th Fl., New York City, New York 10027.