90 l 2026

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The document is a 'Request for Medical Eligibility Determination' form (BHSF Form 90-L) used to assess an individual's need for medical services, including nursing home placement. It collects detailed recipient information, previous care history, and current living arrangements. The form also requires a level of care determination by the attending physician, outlining various levels of care needed based on the patient's condition. Additionally, it includes sections for medical information such as diagnosis, medications, recent hospitalizations, mental status, activities of daily living, special care needs, and physical examination details.

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Click ‘Get Form’ to open the 90 l document in the editor.
Begin by filling out the Recipient Information section. Enter the recipient’s name, Social Security number, and Medicaid number in the designated fields.
Provide the address details including city, state, zip code, and parish. Include information about the responsible party or curator along with their contact details.
In the Living Arrangements section, indicate whether the recipient lives at home, with relatives, or elsewhere. Specify any previous institutional care received by listing facilities and dates.
Complete the Level of Care Determination section by selecting the appropriate level of care required based on your assessment of needs.
Fill in Medical Information including diagnosis, medications (with dosage), recent hospitalizations, and mental status behavior checks.
Finally, review all sections for accuracy before signing and dating at the bottom of the form.

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