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Click ‘Get Form’ to open the Nursing Addendum in the editor.
Begin by entering the client’s name and Medicaid number at the top of the form. Ensure accuracy as this information is crucial for processing.
In the 'Prior Authorization Request Submitter Certification Statement' section, check the box confirming your agreement and provide your initials.
Fill out the 'Nursing Care Plan Summary' by listing problems, goals of care, specific measurable outcomes, and progress toward those goals.
Complete the 'Schedule of Services 24-hour Daily Flow Sheet' using military time. Utilize provided abbreviations for clarity on services rendered.
Finally, ensure all required signatures are obtained from the client/responsible adult, skilled nursing provider(s), and prescribing physician before submission.
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