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Case Mix Review Manual Attachment 6 | Table
of Contents |
Minnesota Department of Health
Case Mix Review
85 East 7th Place, Suite 300, Box 64938
St. Paul, MN 55164-0938 |
ATTACHMENT VI
REQUEST FOR
RECONSIDERATION
OF RESIDENT
CLASSIFICATION |
| NOTE: Facilities making a
request must provide notice of such request to the
resident on the same date the request is submitted to the
department and provide a copy of that
notice with this reconsideration request See
FACILITY MANUAL FOR COMPLETING CASE MIX REQUESTS FOR
CLASSIFICATION, Section VIII. |
Send this form along with documentation to support a requested
classification reconsideration. The request and
documentation must be submitted within 30 days of the receipt of
the notice of classification.
Please provide the following information:
RESIDENT'S NAME________________________________
CMR ID NUMBER ________________
FACILITY NAME__________________________________
FACILITY PHONE # (___)__________
FACILITY ADDRESS
_______________________________ LOCATION NUMBER_____________
| *Date the FACILITY
received the classification notice:___________ |
*To be
completed for FACILITY initiated request only |
| *Date the FACILITY
distributed the notices:___________ |
| Date the
resident/representative received the notice:___________ |
|
| Date the
resident/representative requested documentation:_________ |
| Date the FACILITY
provided documentation to the
resident/representative:______________ |
In order for the Department to establish a basis for
reconsidering the classification:
- Enclose a copy of the resident's assessment form. The
FACILITY must provide a copy of the assessment and
documentation to the resident/representative within three
(3) working days of written request, AND
- Circle the disputed items in black ink, AND
- All areas of this form must be completed as indicated. On
the reverse: Write a brief description of the basis for
your disagreement with items (scores) on the assessment
form, AND
- Attach documentation from the medical record supporting
your reasons for disagreement with the classification.
The documentation must be dated on or prior to the date
the assessment was completed. Note RN Signature
Date on the assessment form
REQUEST SUBMITTED BY:
|
____ AUTHORIZED REPRESENTATIVE OF THE
FACILITY
____ RESIDENT
____ RESIDENT'S AUTHORIZED REPRESENTATIVE |
I signify by my signature that these statements are correct
and factual to the best of my knowledge
SIGNATURE ________________________________________ DATE
____________
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Updated Tuesday, 16-Nov-2010 08:51:37 CST
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