OASIS-C-All - OMB#0938-0760 Expiration date According to...

Info icon This preview shows pages 1–4. Sign up to view the full content.

View Full Document Right Arrow Icon
OMB #0938-0760 Expiration date 7/31/2012 According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection instrument is 0938-0760. The time required to complete this information collection is estimated to average 0.7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850. Home Health Patient Tracking Sheet (M0010) C M S Certification Number: __ __ __ __ __ __ (M0014) Branch State: __ __ (M0016) Branch I D Number: __ __ __ __ __ __ __ __ __ __ (M0018) National Provider Identifier (N P I) for the attending physician who has signed the plan of care : __ __ __ __ __ __ __ __ __ __ UK Unknown or Not Available (M0020) Patient I D Number: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ (M0030) Start of Care Date : __ __ /__ __ /__ __ __ __ month / day / year (M0032) Resumption of Care Date : __ __ /__ __ /__ __ __ __ NA - Not Applicable month / day / year (M0040) Patient Name: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ (First) (M I) (Last) (Suffix) (M0050) Patient State of Residence: __ __ (M0060) Patient Zip Code: __ __ __ __ __ __ __ __ __ (M0063) Medicare Number: __ __ __ __ __ __ __ __ __ __ __ __ NA No Medicare (including suffix) ( M0064) Social Security Number: __ __ __ - __ __ - __ __ __ __ UK Unknown or Not Available (M0065) Medicaid Number: __ __ __ __ __ __ __ __ __ __ __ __ __ __ NA No Medicaid (M0066) Birth Date: __ __ /__ __ /__ __ __ __ month / day / year (M0069) Gender: 1 - Male 2 - Female (M0140) Race/Ethnicity: (Mark all that apply.) 1 - American Indian or Alaska Native 2 - Asian 3 - Black or African-American 4 - Hispanic or Latino 5 - Native Hawaiian or Pacific Islander 6 - White OASIS-C: All Items Centers for Medicare & Medicaid Services August 2009 Page 1 of 24
Image of page 1

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full Document Right Arrow Icon
OMB #0938-0760 Expiration date 7/31/2012 (M0150) Current Payment Sources for Home Care: (Mark all that apply.) 0 - None; no charge for current services 1 - Medicare (traditional fee-for-service) 2 - Medicare (HMO/managed care/Advantage plan) 3 - Medicaid (traditional fee-for-service) 4 - Medicaid (HMO/managed care) 5 - Workers' compensation 6 - Title programs (e.g., Title III, V, or XX) 7 - Other government (e.g., TriCare, VA, etc.) 8 - Private insurance 9 - Private HMO/managed care 10 - Self-pay 11 - Other (specify) UK - Unknown OASIS-C: All Items Centers for Medicare & Medicaid Services August 2009 Page 2 of 24
Image of page 2