CMS CLINICAL ELIGIBILITY ATTESTATION
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1 CMS CLINICAL ELIGIBILITY ATTESTATION Patient Name: DOB: Medicaid and/or KidCare ID: Parent/Legal Guardian Name: Phone number: Initial all that Apply: Initials ICD 10 Descriptor Certain infectious and parasitic diseases B20 Human immunodeficiency virus (HIV) disease Neoplasms C00-D48 All malignancies (except those in remission greater than five years), Disease of the blood and blood-forming organs and certain disorders involving the immune mechanism D D57.1 Hb-SS disease, D66 Hereditary factor VIII deficiency D81.0- D81.4 Severe combined immunodeficiency [SCID], D82.1 Digeorge s syndrome Endocrine, nutritional and metabolic disorders E70.0 Classical phenylketonuria E70.21 Tyrosinemia E71.0 Maple Syrup Urine Disease E Isovaleric acidemia E methylglutaconic aciduria E Methylmalonic acidemia E Propionic acidemia E72.11 homocystinuria E72.22 Arginosuccinic aciduria E72.23 Citrulinemia E74.21 Galactosemia E75.23 Krabbe disease E E E75.25 Metachromatic leukodystrophy E76.01 Hurler's syndrome E76.1 Mucopolysaccharidosis, type II E76.22 Sanfilippo mucopolysaccharidoses E84.0 F20.0- F20.9 Niemann-Pick disease, Cystic fibrosis, Mental, behavioral and neurodevelopmental disorders Schizoprenia Form DH8001-CMS (12/2015) Page 1
![and certain disorders involving the immune mechanism D57.00- D57.1 Hb-SS disease, D66 Hereditary factor VIII deficiency D81.0- D81.4 Severe combined immunodeficiency [SCID], D82.](/docs-images/44/15063852/images/page_1.jpg "1 Digeorge s syndrome Endocrine, nutritional and metabolic disorders E70.0 Classical phenylketonuria E70.21 Tyrosinemia E71.0 Maple Syrup Urine Disease E71.110 Isovaleric acidemia E71.")
2 F25.9 Schizoaffective disorder F30.13 Manic episode, severe, without psychotic symptoms F30.2 Manic episode, severe with psychotic symptoms F31.13 Bipolar disorder, current episode manic without psychotic features, severe F31.2 Bipolar disorder, current episode manic severe with psychotic features F31.4 Bipolar disorder, current episode depressed, severe, without psychotic features F31.5 Bipolar disorder, current episode depressed, severe, with psychotic features F31.63 Bipolar disorder, current episode mixed, severe, without psychotic features F31.64 Bipolar disorder, current episode mixed, severe, with psychotic features F31.81 Bipolar disorder II F33.2 Major depressive disorder, recurrent severe without psychotic features F33.3 Major depressive disorder, recurrent, severe with psychotic symptoms Diseases of the nervous system G31.81 Alpers disease G31.82 Leigh's disease G G40.B19 G71.11 Myotonic muscular dystrophy G80.0 Spastic quadriplegia cerebral palsy G80.1 Spastic diplegic cerebral palsy G80.2 Spastic hemiplegic cerebral palsy Epilepsy, G G82.54 G91.0 Communicating hydrocephalus G91.1 Obstructive hydrocephalus G93.1 Anoxic brain damage, not elsewhere classified Diseases if the eye and adnexa Quadriplegia, H H H H H54.0 Blindness, binocular Diseases of the ear and mastoid process H90.3 Sensorineural hearing loss, bilateral H91.9 Hearing Loss Diseases of the circulatory system I34.0- I34.2 I35.0- I35.2 I36.1- I36.2 I50.1-I50.9 J J45.52 Retinal neovascularization, Retrolental fibroplasia, Nonrheumatic mitral (valve), Nonrheumatic aortic (valve), Nonrheumatic tricuspid (valve), All heart failure, Diseases of the respiratory system Severe persistent asthma, Diseases of the digestive system K72.10 Chronic hepatic failure without coma K72.11 Chronic hepatic failure with coma Form DH8001-CMS (12/2015) Page 2
3 Diseases of the musculoskeletal system and connective tissue M M08.48 Juvenile rheumatoid arthritis, M32.0-M32.9 Systemic lupus erythematosus M91.11 Juvenile osteochondrosis of head of femur [Legg-Calve-Perthes], right leg M91.12 Juvenile osteochondrosis of head of femur [Legg-Calve-Perthes], left leg Diseases of the genitourinary system N18.4 Chronic kidney disease stage IV (severe) N18.5 Chronic kidney disease stage V N18.6 End stage renal disease Certain conditions originating in the perinatal period P27.0 Wilson-Mikity syndrome P27.1 Bronchopulmonary dysplasia originating in the perinatal period P52.21 Intraventricular (nontraumatic) hemorrhage, grade 3, of newborn P52.22 Intraventricular (nontraumatic) hemorrhage, grade 4, of newborn P78.81 Congenital cirrhosis (of liver) P96.0 Congenital renal failure Congenital malformations, deformations, and chromosomal abnormalities Q00.0 Anencephaly Q00.1 Craniorachischisis Q00.2 Iniencephaly Q01.0 Frontal encephalocele Q01.1 Nasofrontal encephalocele Q01.2 Occipital encephalocele Q03.0 Malformations of aqueduct of Sylvius Q03.1 Atresia of foramina of Magendie and Luschka Q04.2 Holoprosencephaly Q04.4 Septo-optic dysplasia of brain Q04.5 Megalencephaly Q05.0- Q05.3 and Q05.5- Q05.8 Spina bifida, (list specific ICD10 code and descriptor) Q06.0 Amyelia Q06.1 Hypoplasia and dysplasia of spinal cord Q Q07.03 Q20.0 Common Arterial Trunk Q20.1 Double outlet right ventricle Q20.3 Discordant ventriculoarterial connection Q20.4 Double inlet ventricle Q21.3 Tetralogy of Fallot Q22.0 Pulmonary valve atresia Q22.5 Ebstein's anomaly Q22.6 Hypoplastic right heart syndrome Q23.4 Hypoplastic left heart syndrome Q24.6 Congenital heart block Q25.1 Coarctation of aorta Q25.2 Atresia of aorta Q26.2 Total anomalous pulmonary venous connection Q33.3 Agenesis of lung Arnold-Chiari syndrome, Form DH8001-CMS (12/2015) Page 3
4 Q33.6 Congenital hypoplasia and dysplasia of lung Q35.1 Cleft hard palate Q35.3 Cleft soft palate Q35.5 Cleft hard palate with cleft soft palate Q37.0 Cleft hard palate with bilateral cleft lip Q37.1 Cleft hard palate with unilateral cleft lip Q37.2 Cleft soft palate with bilateral cleft lip Q37.3 Cleft soft palate with unilateral cleft lip Q37.4 Cleft hard and soft palate with bilateral cleft lip Q37.5 Cleft hard and soft palate with unilateral cleft lip Q39.1 Atresia of esophagus with tracheo-esophageal fistula Q43.1 Hirschsprung's disease Q44.3 Congenital stenosis and stricture of bile ducts Q60.1 Renal agenesis, bilateral Q75.1 Craniofacial dysostosis (Crouzan Syndrome) Q75.4 Mandibulofacial dysostosis (Treacher Collins) Q75.5 Oculomandibular dysostosis (Hallermann-Streiff syndrome) Q76.1 Klippel-Feil syndrome Q78.0 Osteogenesis imperfecta Q91.0- Q91.2 Trisomy 18, nonmosaicism, Q91.4-Q91.6 Trisomy 13, Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified R40.3 Persistent vegetative state Injury, poisoning and certain other consequences of external causes T74.1 Physical abuse, confirmed, T74.3 Psychological abuse, confirmed, T74.4XXA- T74.4XXS Shaken infant syndrome, Factors influencing health status and contact with health services Z21 Z76.82 Awaiting organ transplant status Z94.0 Kidney transplant status Z94.1 Heart transplant status Z94.2 Lung transplant status Z94.3 Heart and lungs transplant status Z94.4 Liver transplant status Z94.81 Bone marrow transplant status Asymptomatic human immunodeficiency virus [HIV] infection status I attest that the child identified above is actively under my care for the management of the chronic and serious condition(s) identified on this form by my initials. I attest that my patient is under 21 years of age with a chronic physical, developmental, behavioral, or emotional condition, and also requires health care and related services of a type or amount beyond that which is generally required by children. Form DH8001-CMS (12/2015) Page 4
5 I attest my patient has functional limits related to his or her ability to do the things most children of the same age can do. I understand this attestation will be used to establish my patient's clinical eligibility for the CMS Managed Care Plan based on the qualifying diagnoses. Signed: Print Name: Medicaid #: Date: INSTRUCTIONS: AFTER COMPLETION OF FORM, RETURN TO FLORIDA DEPARTMENT OF HEALTH, OFFICE OF THE CMS MANAGED CARE PLAN BY WAY OF (CMS.ClinicalEligibilityScreening@flhealth.gov); FACSIMILE ( ); OR MAIL (Attention: Clinical Eligibility, 4052 Bald Cypress Way, Bin A-06, Tallahassee, Florida, 32399). Form DH8001-CMS (12/2015) Page 5
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