Dma-3050R. Adult Care Home Personal Care Physician Authorization and Care Plan 2025

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The document is a Personal Care Physician Authorization and Care Plan for residents in an adult care home. It includes sections for resident information, assessment of medical and personal care needs, mental health history, ambulation, nutrition, respiration, skin care, bowel and bladder management, orientation, vision, hearing, speech/communication methods, and a detailed care plan outlining assistance required for activities of daily living (ADLs). The document also requires certification from the assessor and physician to ensure appropriate care services are provided.

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Click ‘Get Form’ to open the dma-3050R in the editor.
Begin by entering the resident's information in the designated fields, including name, sex, date of birth, and Medicaid ID number.
Complete the assessment section by detailing medications, mental health history, ambulation status, nutrition needs, and any other relevant health information.
In the care plan section, specify the type of assistance needed for each activity of daily living (ADL) and check off the days of the week when assistance is provided.
Ensure that both the assessor and physician provide their signatures and dates at the end of the form to validate the authorization.

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