West Virginia Department of Health and Human Resources ICF/IID Level of Care Evaluation - Appendix-DD-2A - Medical Assessment Form

Aug 30, 2026

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ICF/IID level of care evaluation form for the West Virginia Department of Health and Human Resources, covering required intake and physician-completed medical assessment. The document collects demographic details, medication lists, health history, living arrangement, legal representative information, and medical findings including allergies, vitals, systems review, neurological status, and special-care needs. It also includes diagnostic classification (Axis I–III), prognosis and recommendations, physician certification for intermediate care facility eligibility, and departmental approval fields.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages3

Reading Time8 min

AccessFree to download

Demographic Information

Medical Assessment (Physician)

Medical Findings and Codes

Problems Requiring Special Care

Therapeutic Modalities, Difficulties, and Support Needs

Diagnostic Section (Axis I–III)

Prognosis, Recommendations, and Certification

Department Use Only (Approval)

West Virginia Department of Health and Human Resources ICF/IID Level of Care Evaluation Initial Annual Renewal Service Coordination Agency: Address: Service Coordinator: Contact Person: Date: ___________________________________________________________________________ I. DEMOGRAPHIC INFORMATION (MAY BE COMPLETED BY SERVICE COORDINATOR OR FAMILY MEMBER) | 1. Individual’s Full Name | | | 2. Sex:
F M | | | | 3. Medicaid \# (Required) | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | 4. Address (including Street/Box, City, State & Zip)
____________________________________________________________________________ ____________
Phone: ( ) | | | | | | | | | | | 5. County | 6. Social Security \# | | | | 7. Birthdate (MM/DD/YY) | | | 8. Age | 9. Phone | | 10.Spouse’s Name | | | 11. Address (if different from above) | | | | | | | | 12. List Current Medications
Name of Medication Dosage | | | | Date Started | | Reason | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | 13. Check if applicant has any of the following:
Guardian Power of Attorney Other
Committee Durable Power of Attorney
Medical Power of Attorney Living Will
Name & Address of Representative:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Phone ( ) | | | | | | | | | | | 14. Living Arrangement
Natural/Adoptive Family Specialized Family Care Provider ISS–Two Person (Intensive support setting)
Group Home (4 or more persons) ISS–One Person (Intensive support setting) ISS–Three Person (Intensive support setting) | | | | | | | | | | | 15. Significant Health history –(include recent hospitalization(s) and/or surgery(ies) with dates, history of infectious disease)
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________ | | | | | | | | | | II. MEDICAL ASSESSMENT (MUST BE COMPLETED BY PHYSICIAN) NAME: DATE: | 16. Height: | Weight: | BP: | P: | R: | T: | | --- | --- | --- | --- | --- | --- | | 17. Allergies: | | | | | | CODE: √ = NORMAL N = NOT DONE (PLEASE EXPLAIN WHY) NA = NOT APPLICABLE X = ABNORMAL (PLEASE DESCRIBE) | SKIN | | | | --- | --- | --- | | EYES/VISION | | | | NOSE | | | | THROAT | | | | MOUTH | | | | SWALLOWING | | | | LYMPH NODES | | | | THYROID | | | | HEART | | | | LUNGS | | | | BREAST | | | | ABDOMEN | | | | EXTREMi~~E~~TIES | | | | SPINE | | | | GENITALIA | | | | RECTAL (MALES INCLUDE PROSTATE) | | | | BI-MANUAL VAGINAL | | | | VISION | | | | DENTAL | | | | HEARING | | | NEUROLOGICAL | ALERTNESS | | | | --- | --- | --- | | COHERENCE | | | | ATTENTION SPAN | | | | SPEECH | | | | SENSATION | | | | COORDINATION | | | | GAIT | | | | MUSCLE TONE | | | | REFLEXES | | | NAME DATE II. MEDICAL ASSESSMENT (CONTINUED) Problems requiring Special Care (check all appropriate blanks) MOBILITY Ambulatory Ambulatory w/human help Ambul. w/ Mechanical help Wheelchair self-propelled Wheelchair w/ assistance Transfer w/ assistance Immobile PERSONAL HYGIENE/SELF CARE Independent

FAQs

Who is responsible for completing each part of the ICF/IID level of care evaluation?

Demographic information may be completed by the service coordinator or family member, while the medical assessment must be completed by the physician.

What medical assessment sections and coding guidance are included?

The form gathers vitals and allergies, provides a systems checklist with coding symbols (including normal, abnormal, and not done with explanations), and documents neurological findings and functional difficulties requiring special care.

What certification does the physician provide in the document?

The physician certifies that the patient’s developmental disability, medical condition, and related health care needs are documented and that the patient requires the level of care and services provided in an “INTERMEDIATE CARE FACILITY” for individuals with intellectual disability and/or related conditions.

Aug 30, 2026

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