Healthcare Level of Care Determination

Healthcare Level of Care Determination

Patient Name:    DOB:    Medical Record #:

Patient Information

Insurance / Authorization

Referral / Request

Referral Date:    Contact Phone:

Clinical Summary

Functional, Cognitive & Behavioral Status

Mobility assistance required:    None    Cane/walker    Full assistance

Activities of Daily Living limitations (select all that apply):
Bathing    Dressing    Transferring    Toileting    Feeding

Cognitive / Behavioral concerns:    None    Delirium/acute confusion    Dementia    Behavioral dysregulation

Medical Necessity Criteria & Clinical Findings

The clinician attests that the following objective findings support the requested level of care (select all that apply and provide supporting documentation):

Acute medical instability requiring 24-hour monitoring or interventions (e.g., hemodynamic support, respiratory support)
Need for reasonable and necessary skilled nursing services (e.g., IV therapy, complex wound care)
Need for intensive interdisciplinary rehabilitation requiring 24-hour nursing and therapy coordination
Complex wound management requiring skilled procedures and daily reassessment
Frequent medication titration or parenteral therapies requiring skilled administration
Behavioral issues posing significant safety risk requiring supervised environment

Recommended Level of Care

Select recommended level of care (select the single most appropriate option and justify):
Inpatient Acute Care
Inpatient Rehabilitation (IRF)
Long-Term Acute Care (LTAC)
Skilled Nursing Facility (SNF)
Home Health with skilled visits
Hospice care (comfort-focused)
Outpatient services (therapy / clinic)

Risk Assessment & Care Needs

Identified risks requiring the recommended setting (select all that apply):
High fall risk requiring supervision/assistive device
Active infection requiring monitoring or IV antibiotics
Wound requiring skilled daily dressing changes
Nutritional support / tube feeding
Respiratory support (e.g., oxygen management, ventilator wean)
Need for frequent medication administration or monitoring

Clinician Attestation

I attest that the information provided herein is true and accurate to the best of my knowledge and is based upon the patient’s medical record, direct clinical examination, and available objective data. This recommendation is based on reasonable clinical judgment and conforms to generally accepted standards of care for the stated diagnoses.

Date of clinical assessment:

Authorization & Patient Acknowledgment

By signing below, the patient or authorized representative authorizes the release and use of medical records and clinical information necessary to complete the level of care determination, including but not limited to physician notes, nursing notes, medication records, diagnostic test results, and therapy notes. This authorization is limited to the purpose of assessment, coverage determination, and care planning.

The patient acknowledges understanding that this determination is an assessment of medical necessity for the recommended level of care. The patient retains the right to request internal or external review consistent with insurer and provider policies. This authorization expires on the Authorization Expiration Date entered above unless earlier revoked in writing. Revocation will not affect disclosures already made in reliance on this authorization.

Certification: I understand that intentional submission of false information may have legal or administrative consequences.

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