[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-detail-160293-en":3,"doc-seo-160293-105":30,"detail-sidebar-cat-0-en-105":90},{"code":4,"msg":5,"data":6},0,"success",{"doc_id":7,"user_id":8,"nickname":9,"user_avatar":10,"doc_module":4,"category_id":11,"category_name":12,"doc_title":13,"doc_description":14,"doc_content":15,"file_id":16,"file_url":17,"file_type":18,"file_size":19,"view_count":4,"is_deleted":4,"is_public":20,"is_downloadable":20,"audit_status":20,"page_count":21,"language":22,"language_code":23,"site_id":24,"html_lang":23,"table_of_contents":25,"faqs":26,"seo_title":27,"seo_description":14,"update_tm":28,"read_time":29},160293,549758252649,"Ivy","https://ap-avatar.wpscdn.com/avatar/8000253669c5317157?_k=1778319167496531819",7,"Healthcare","West Virginia Department of Health and Human Resources ICF/IID Level of Care Evaluation - Appendix-DD-2A - Medical Assessment Form","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.","West Virginia Department of Health and Human Resources ICF/IID Level of Care Evaluation  \nInitial Annual Renewal  \nService Coordination Agency:   Address:    Service Coordinator:   Contact Person:   Date:  \n___________________________________________________________________________  \nI. DEMOGRAPHIC INFORMATION (MAY BE COMPLETED BY SERVICE COORDINATOR OR FAMILY MEMBER)  \n\n| 1. Individual’s Full Name |  |  | 2. Sex:\u003Cbr>F M |  |  |  | 3. Medicaid \\# (Required) |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| 4. Address (including Street/Box, City, State & Zip)  \u003Cbr>____________________________________________________________________________ ____________\u003Cbr>Phone: ( ) |  |  |  |  |  |  |  |  |  |\n| 5. County | 6. Social Security \\# |  |  |  | 7. Birthdate (MM/DD/YY) |  |  | 8. Age | 9. Phone |\n| 10.Spouse’s Name |  |  | 11. Address (if different from above) |  |  |  |  |  |  |\n| 12. List Current Medications\u003Cbr>Name of Medication  Dosage |  |  |  | Date Started |  | Reason |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |\n| 13. Check if applicant has any of the following:\u003Cbr> Guardian  Power of Attorney  Other \u003Cbr> Committee  Durable Power of Attorney\u003Cbr> Medical Power of Attorney  Living Will\u003Cbr>Name & Address of Representative:\u003Cbr>_______________________________________________________________\u003Cbr>_______________________________________________________________\u003Cbr>_______________________________________________________________\u003Cbr>Phone ( ) |  |  |  |  |  |  |  |  |  |\n| 14. Living Arrangement\u003Cbr> Natural/Adoptive Family  Specialized Family Care Provider  ISS–Two Person (Intensive support setting)\u003Cbr> Group Home (4 or more persons)  ISS–One Person (Intensive support setting)  ISS–Three Person (Intensive support setting) |  |  |  |  |  |  |  |  |  |\n| 15. Significant Health history –(include recent hospitalization(s) and/or surgery(ies) with dates, history of infectious disease)\u003Cbr>______________________________________________________________________________________\u003Cbr>______________________________________________________________________________________\u003Cbr>______________________________________________________________________________________\u003Cbr>______________________________________________________________________________________\u003Cbr>______________________________________________________________________________________ |  |  |  |  |  |  |  |  |  |\n\nII. MEDICAL ASSESSMENT (MUST BE COMPLETED BY PHYSICIAN) NAME:  DATE:   \n\n| 16. Height: | Weight: | BP: | P: | R: | T: |\n| --- | --- | --- | --- | --- | --- |\n| 17. Allergies: |  |  |  |  |  |\n\nCODE: √ = NORMAL N = NOT DONE (PLEASE EXPLAIN WHY) NA = NOT APPLICABLE X = ABNORMAL (PLEASE DESCRIBE)  \n\n| SKIN |  |  |\n| --- | --- | --- |\n| EYES/VISION |  |  |\n| NOSE |  |  |\n| THROAT |  |  |\n| MOUTH |  |  |\n| SWALLOWING |  |  |\n| LYMPH NODES |  |  |\n| THYROID |  |  |\n| HEART |  |  |\n| LUNGS |  |  |\n| BREAST |  |  |\n| ABDOMEN |  |  |\n| EXTREMi~~E~~TIES |  |  |\n| SPINE |  |  |\n| GENITALIA |  |  |\n| RECTAL (MALES INCLUDE PROSTATE) |  |  |\n| BI-MANUAL VAGINAL |  |  |\n| VISION |  |  |\n| DENTAL |  |  |\n| HEARING |  |  |\n\nNEUROLOGICAL  \n\n| ALERTNESS |  |  |\n| --- | --- | --- |\n| COHERENCE |  |  |\n| ATTENTION SPAN |  |  |\n| SPEECH |  |  |\n| SENSATION |  |  |\n| COORDINATION |  |  |\n| GAIT |  |  |\n| MUSCLE TONE |  |  |\n| REFLEXES |  |  |\n\nNAME   DATE    \nII. MEDICAL ASSESSMENT (CONTINUED)  \nProblems requiring Special Care (check all appropriate blanks)  \nMOBILITY    \nAmbulatory    \nAmbulatory w/human help    \nAmbul. w/ Mechanical help    \nWheelchair self-propelled    \nWheelchair w/ assistance    \nTransfer w/ assistance    \nImmobile    \nPERSONAL HYGIENE/SELF CARE Independent   ","cbCaiam01VEOUnoD","https://ap.wps.com/l/cbCaiam01VEOUnoD","pdf",346109,1,3,"English","en",105,"# Demographic Information\n# Medical Assessment (Physician)\n## Medical Findings and Codes\n## Problems Requiring Special Care\n## Therapeutic Modalities, Difficulties, and Support Needs\n## Diagnostic Section (Axis I–III)\n## Prognosis, Recommendations, and Certification\n## Department Use Only (Approval)","[{\"question\":\"Who is responsible for completing each part of the ICF/IID level of care evaluation?\",\"answer\":\"Demographic information may be completed by the service coordinator or family member, while the medical assessment must be completed by the physician.\"},{\"question\":\"What medical assessment sections and coding guidance are included?\",\"answer\":\"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.\"},{\"question\":\"What certification does the physician provide in the document?\",\"answer\":\"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.\"}]","West Virginia Department of Health and Human Resources ICF/IID Level of Care Evaluation - 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