4.00 Appendix 5 Physician Notification of Care Plan
Home and Community Based Services Manual
4.00 Appendix 5 Physician Notification of Care Plan
The Physician Notification of Care Plan (HCBS-11) is necessary to provide the participant’s Primary Care Physician (PCP) an opportunity for input on the development of a Person-Centered Care Plan (PCCP) for their patient. The HCBS-11 shall be mailed within three (3) business days of the initial approval of the PCCP for all recipients of Home and Community Based Services (HCBS) authorized by the DHSS, Division of Senior and Disability Services (DSDS), or its designee.
Instructions
TO: Enter the physician’s name and mailing address.
RE: Enter the participant’s name.
DCN: Enter the participant’s Departmental Client Number (DCN).
DATE: Enter the date the form is completed.
ASSESSOR SIGNATURE: The individual completing the form shall sign the document.
ASSESSOR NAME: The individual completing the form shall print their name.
TELEPHONE: Enter the telephone number of the assessor.
MAILING ADDRESS: Enter the mailing address of the assessor.
FAX NUMBER: Enter the fax number of the assessor.
PHYSICIAN SECTION: It is not required for this form and/or the PCCP to be returned by the PCP. However, the PCP may choose to enter comments in the Physician Comment section and return it to the assessor. If returned, staff shall review information provided, complete any necessary follow up action, and upload the returned form into the electronic case record.
Distribution
The form shall be sent to the PCP, along with a copy of the associated PCCP, and be uploaded to the electronic case record.