NCTracks uses this one-page form to tie a physician's signature to a level-of-care request entered online for an NC Medicaid beneficiary. The physician verifies that they provided the information on the state approved level of care form and that it is accurate, and marks the level they assessed, from nursing facility or ventilator care to CAP or PACE.
The physician who assessed the beneficiary marks the level of care, fills in the recipient name and ID and the determination date, and signs. The receiving facility's name and the move date are added if known.
Download the current version from the source each time; forms change without notice.
Physician's Signature for Authorization of Level of Care
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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It is the physician's signature page for a level-of-care request submitted through NCTracks. By signing, the physician verifies that they provided the information on the state approved level of care form for the beneficiary, that it is accurate, and which level of care they assessed as appropriate.
No. NCTracks lists it under prior approval attachments, which accompany a primary request and do not create one. NCTracks warns that an attachment sent without its request may be delayed or not received at all, so it should go with the level-of-care request it supports.