Medicare functional assessment form 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name, date of birth, and member ID number at the top of the form. This information is crucial for identifying the patient.
3. In the Cognitive Status section, circle 'Intact' or 'Impaired' based on the patient's condition. If impaired, specify if they are depressed or not oriented to person, place, or time.
4. For Ambulation Status, select from options like 'Normal/Good', 'Fair', or 'Poor'. Indicate if an assistive device is needed by marking 'Y' or 'N'.
5. Assess Sensory Ability by marking whether the patient is independent in mobility and hearing. Circle any devices used for assistance.
6. Evaluate Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). Circle whether assistance is required and specify types of help needed.
7. Complete sections on Advance Care Planning and Comprehensive Pain Assessment by answering yes/no questions and providing details where necessary.
8. Finally, ensure that a physician's signature and date are included at the bottom before saving your completed form.

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