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Omitting any information requested below will delay approval and jeopardize a participants eligibility for continued enrollment in PACE.  FORMCHECKBOX  Justification summary from IDT  FORMCHECKBOX  Initial and updated LOC assessment  FORMCHECKBOX  Diagnosis of chronic or disabling condition  FORMCHECKBOX  Last comprehensive assessment by all relevant disciplines  FORMCHECKBOX  Last 2 IDT care plans  FORMCHECKBOX  History and Physical  FORMCHECKBOX  Physician and nursing progress notes  FORMCHECKBOX  All specialty consultant notes (any discipline) '-HO# ) * D Q S b c e g p r   ƺwsh`jh`5UmHnHujh`5U h`5jh`5U h`CJho*5>*CJhn&5>*CJhB hn&5>*CJhB hB 5>*CJ h/2CJ hn&>*CJ hn&CJ h>* hn&>* hrk>* hB CJ hn&CJ-.Pdo   8 u[kdt$$IfTH4p0HNq #44 Haf4ytw%T $Ifgdw% $Ifgdw%$a$ $$d N a$$  8 : N P R \ ^ ` b   $ & ( 2 4 6 8 : < > @ B d f z ~v~v~hgh`5 hgh`jRh`5U h @ mddXd $$Ifa$gdw% $Ifgdw%{kd$$IfTHp\HN n_  44 Haytw%T x$Ifgdw% $Ifgdw%@ B d vvhv$$Ifa$gdw% $Ifgdw%~kdg$$IfTH\HN q  44 Haytw%Tz |     ( * , 6 8 : j l n ޼ɭӦӦޙɭɦӦތɭɦӃ}wqw h/2CJ hn&CJ h`CJhgh`CJjh`5Ujh`5U hgh`jh`5UmHnHujmh`5Ujh`5Uh` h*CJ hn&CJ h;CJ1((((#($(2(3(4(Y(Z(h(i(j((((((((((((((()))))⦠|rm`jh`5U h`5jh`5Uhlh`CJj[h`CJUjh`CJUh` h`CJ h`CJj hn&CJUj hn&CJUj hn&CJUj* hn&CJUU hn&CJjhn&CJUj hn&CJU% FORMCHECKBOX  Social work notes  FORMCHECKBOX  Diagnostic tests supporting request  FORMCHECKBOX  Medication and treatment record  FORMCHECKBOX  Other relevant documentation supporting the request Above request is: FORMCHECKBOX  Authorized/Date: FORMTEXT ((),\,, $If^ `gdw% $Ifgdw%  $If^ gdw%Hkd$$IfTH4p D!44 Haf4ytw%T      FORMCHECKBOX  Not Authorized/Date: FORMTEXT      Name and Title of Reviewer: FORMTEXT      Signature:Date: FORMTEXT      Telephone: FORMTEXT           CP-3 MAR 18 )*, , ,,,,,.,0,2,N,\,^,r,t,v,,,,,,,,,,,,,,--$-&-(-2-4-L-N-b-d-f-p-r-t-v-x-кЩЩ| hn&CJj7h`5Ujh`5Ujh`5Uh`jh`5Uhgh`CJjEh`CJU h`CJjh`CJU h`5jh`5UmHnHuUjh`5U.,,,,xm $Ifgdw% $Ifgdw%~kd/$$IfTH5\6 n ~ 8\ 244 Haytw%T,,,---6-L-t- $Ifgdw% $If^gdw% $Ifgdw%[kd>$$IfTH4p0  L44 Haf4ytw%Tt-v-x-|-~----GEEEEEEkd$$IfTH4 ֞8 'q J*44 Haf4ytw%Tx-z-~-------------- hn&CJhw% ho*CJ hCJhjhU---------0&P1h/ =!8"8#$%@ tDText1$$If!vh#v #v#:V H4p,5 5#/ / 4 Haf4ytw%TtDText1z$$If!vh#v #v#:V H4,5 5#/ 4 Haf4ytw%TtDText1z$$If!vh#v #v#:V H4p,5 5#/ 4 Haf4ytw%TtDText1tDText1$$If!vh#v #v #v#v:V Hp,,5 5 55/ / 4 Haytw%T$$If!vh#v #v #v#v:V H,5 5 55/ 4 Haytw%TtDText1tDText1$$If!vh#v8#v#vN #vV:V H|=,5855N 5V/ / 4 Haytw%TtDText1tDText1$$If!vh#v8#v#vN #vV:V H=,5855N 5V/ / 4 Haytw%T$$If!vh#v#v:V H4p82,55/ 4 Haf4ytw%TtDeCheck1tDeCheck2tDeCheck3tDeCheck4tDeCheck5tDeCheck6tDeCheck7tDeCheck8tDeCheck9vDeCheck10vDeCheck11vDeCheck12Y$$If!vh#vD!:V H4p,5D!4 Hf4ytw%TvDeCheck13tDText2vDeCheck14tDText1$$If!vh#v~ #v8#v\ #v2:V H5,5~ 585\ 52/ / 4 Hytw%TtDText1$$If!vh#v #vL:V H4p,5 5L/ / 4 Hf4ytw%TtDText1tDText1$$If!vh#v#vq #v#vJ#v#v*#v:V H4 ,,55q 55J55*5/ / / 4 Hf4ytw%T^ 666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nHsH tHH`H Normal CJOJQJ_HaJmH sH tH B@B  Heading 1 $@&a$ 5>*\DA D Default Paragraph FontRi@R 0 Table Normal4 l4a (k ( 0No List 4>@4 Titlea$ 5CJ\44 Header !4 @4 Footer !H@"H ;0 Balloon TextCJOJQJ^JaJNo1N ;0Balloon Text CharCJOJQJ^JaJB'`AB o*0Comment ReferenceCJaJ<@R< o*0 Comment TextCJaJBoaB o*0Comment Text CharOJQJ@j@QR@ o*0Comment Subject5\NoN o*0Comment Subject Char5OJQJ\PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! 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