Delaware Health and Social Services DIVISION OF SUBSTANCE ABUSE AND MENTAL HEALTH LONG TERM CARE PROGRAM (LTC) RECERTIFICATION FORM PART I (Completed by the LTC Provider) Primary Service Provider and Program: __________________________________________________ Consumer Name _________________________________________________________ Last First M.I. Consumer MCI # ___ ___ ___ ___ ___ ___ DOB ___ ___ ___ ___ ___ ___ ___ ___ M M D D Y Y Y Y Medicaid ___YES ___NO X __________________________________ (Agency Authorized Representative) PART II Physician Recertification (Due 15 days before current certification period ends) Admission Date _____/_____/_____ Date Current Certification Terminates _____/_____/_____ Certification Due Date _____/_____/_____ (15 days before Termination) Based on the indications of the DSAMH Annual Long Term Care Re-Determination Application reviewed on ____/____/_____ (date) and my examination of ____/____/____ (date) documented in the client record, I hereby certify that the following community support rehabilitation services (_____ are) (____ are not) medically necessary for the above named consumer. (Note: submit clinical justification and psychiatric evaluation if services are not medically necessary.) ___ CRISP ___ ACT ___ ICM ___ Licensed MH Group Home Recertification Effective Date ____/____/____ End Date ____/____/____ X _______________________________ (Physician) ____/____/____ (Date) PART III EEU Review of Certification (Completed by EEU; due 5 days after recertification) The physician’s certification have been reviewed by the Eligibility and Enrollment Unit and found to be complete. X ________________________________ (EEU Staff) Date ____/____/____ 3/27/12