New Jersey Department of Health

HIV Home Care Program

PHYSICIAN CERTIFICATION AND PLAN OF CARE

Name of Client

Certification Period

From:

To:

(Recertification every 60 Days)
Diagnosis(es)

The service plan developed by the case manager for the above‑named client includes the following services (indicated by a check mark) which are covered by the HIV Home Care Program:

CASE MANAGEMENT

Case Management: Initial and Monthly

PARAPROFESSIONAL CARE

Homemaker/Home Health Aide Services: __________ hours/day __________ days/week

Personal Care Attendant: __________ hours/day __________ days/week

PROFESSIONAL CARE

Routine Nursing: Number of visits/week __________

Occupational Therapy: Evaluation and/or number of visits/week __________

Physical Therapy: Evaluation and/or number of visits/week __________

Speech Therapy: Evaluation and/or number of visits/week __________

Medical Social worker: Evaluation and/or number of visits/week __________

SPECIALIZED CARE

Intravenous Drug Therapy and IV Prescription Drugs: Number of days/week __________

Specific Drugs: ________________________________________________

Respiratory Therapy: Number of visits/week __________

Routine Diagnostic/Monitoring Tests: Number of days/week __________

Specific Test(s): ________________________________________________

OTHER SERVICES

Medical Day Care: Number of days/week __________

Durable Medical Equipment, Specifically: ________________________________________________

_______________________________________________________________________________
Name of Physician (Print)

Address

Signature	Date

If the service plan is medically appropriate and directly related to this client’s HIV infection, please sign and return this form to:

Case Manager:	__________________________________________________________

Agency Name:	__________________________________________________________

Address:	__________________________________________________________

__________________________________________________________

Telephone No.:	__________________________________________________________

DHAS-10

JUL 12

DHAS-10, Physician Certification and Plan of Care

New jersey Department of Health, Division of HIV, STD and TB Services, HIV Home Care Program

EWhite

2003-12-10

NJDOH