Mutual of Omaha uses this two-page physician form when a long-term care insurance policyholder applies for benefits. The attending physician documents principal diagnoses, any organic mental impairment and how it was diagnosed, which activities of daily living the patient cannot perform without human assistance, services in place, the recommended plan of care and the expected course of functional status.
The attending physician completes the whole form and signs it with tax ID. The claimant or legal representative completes the separate Application for Long Term Care Benefits (M20339PO) and the authorization (M23333).
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Application for Long Term Care Benefits – To Be Completed by the Attending Physician
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Item 7 lists eating, toileting, transferring, bathing, dressing and continence. The physician marks each activity the patient cannot perform without human assistance and gives the date the capability ended and the expected recovery date.
Item 11 offers improvement in functional status in under three months or in three to six months, no change, or deterioration in under three months or in six to twelve months. Item 10 asks for the recommended plan of care with treatments, therapies and expected duration.