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Questionnaire for Enteral Nutrition (pdf) - Illinois - www2 illinois

Questionnaire for Enteral Nutrition (pdf) - Illinois - www2 illinois 2025

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The document is a questionnaire from the State of Illinois Department of Healthcare and Family Services designed for the initial certification, recertification, or change in prescription for participants requiring enteral nutrition. It collects participant information, general health conditions, details about enteral nutrition products used, clinical assessments related to dietary needs, and eligibility for WIC (Women, Infants, and Children) services. The form requires signatures from practitioners and includes sections for documenting medical necessity and nutritional assessments.

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Click ‘Get Form’ to open the Questionnaire for Enteral Nutrition in our editor.
Begin by filling out the 'Participant Information' section. Enter the participant's name, RIN, and birth date accurately.
In the 'Participant General Condition' section, provide details such as estimated duration of need for enteral nutrition, height, weight, and body mass index. If applicable, include growth percentage and any weight loss over the last six months.
Move to the 'Enteral Nutrition' section. List each product being used along with the daily cans and calories consumed. Calculate total caloric intake from both enteral and non-enteral sources.
If applicable, complete the 'Clinical Assessment' section by providing necessary clinical documentation regarding dietary modifications and participant's ability to tolerate foods.
For WIC eligibility (if under 5 years), attach a current WIC letter and indicate if the participant is eligible.
Finally, ensure that all required signatures are provided in the 'Certification' section before submitting your form.

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Who are candidates for enteral nutrition?

Enteral feeding supply allowances (B4034, B4035, and B4036) include all supplies, other than the feeding tube and nutrients, required for the administration of enteral nutrients to the beneficiary for one day. Only one unit of service may be billed for any one day.

What are the nutritional guidelines for enteral nutrition?

Enteral nutrition (EN) provides critical macro and micronutrients to individuals who cannot maintain sufficient oral intake to meet their nutritional needs. EN is most commonly required for neurological conditions that impair swallow function, such as stroke, amytrophic lateral sclerosis, and Parkinsons disease.

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