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Wheeled Mobility Letter of Medical Necessity Form

*INDIVIDUAL’S Janie Doe *ID 000000000

MEMBER INFORMATION AND BACKGROUND

*1. Date of Birth (mm/dd/yyyy): 00/00/0000 2. Date of Evaluation (mm/dd/yyyy): 01/30/2014

*3.

Address Line 1: Superior Rehab Nursing Facility

Address Line 2: 000 Main Street

City: Anytown State: CT Zip Code: 00000

*4.

Evaluation Location Address L1: Superior Rehab Nursing Facility

Evaluation Location Address L 2: 000 Main Street

Evaluation City: Anytown Evaluation State: CT Evaluation Zip Code: 00000

5. Height: 5 FT 5 IN Weight: 148 LBS

6. Professionals Present: Name Credentials Agency

Mary Otherapist MS, OTR Superior Rehab Nursing Facility

Jane Wondernurse RN Superior Rehab Nursing Facility

*7. DME Provider Evaluator: Jay Doe ATP ABC Wheelchair Company

8. Not Required for SNF/ICF Residents

Caregiver/Family: Present During Evaluation?

*9. Prescribing Physician: Johnney A. Doe, MD

*10. Physician Phone Number: 000-000-0000

*11.

Physician Agency: Internal Medicine Specialists, Inc

Physician Address: 00000 Main Street

Physician City: Anytown Physician State: CT Physician Zip Code: 000000

12.

a. Primary Reason for Evaluation:

Initial Wheeled Mobility Deviceb. Primary Issues Relating to DME (explain in 12c):

Size

Replacement Does not address current medical needs

Modification/Repairs Does not address current functional needs

c. Other Pertinent Information; i.e., additional information from 12b,

rationale for replacement vs. modification, repair history, other

information regarding request:

N/A

13. General Description of DME Recommendation:

Invacare Solara 3G Tilt-in-Space wheelchair with Matrx PB Contoured back and High Profile ROHO seat cushion

HUSKY Health Wheeled Mobility LMN Word Form 11.01.2013 1


*INDIVIDUAL’S Janie Doe *ID 000000000

14. DIAGNOSIS(ES), INCLUDING RECENT SURGERIES AND DATES OF SURGERIES RECENT CHANGE IN MEDICAL STATUS

Right CVA with resulting Left hemiplegia, apraxia, and left side visual neglect (8/15/13) YESsee 14a NO NA

Left CVA and MCA with resulting expressive aphasia (2009) YESsee 14a

NO NA

Hx of Hypertension, DM II, alcoholism, IV drug abuse YESsee 14a

NO NA

YESsee 14a

NO NA

YESsee 14a

NO NA

14a. Explain recent change in medical condition and/or

other relevant information including symptoms,

treatments, interventions and medications:

Previously living at home before Right CVA; transferred from the hospital on 8/21/13

Baclofen pump insertion 4/15/2013 since oral medication ineffective to address spasticity and associated pain (see physician's note 4/01/2013)

15. How will the person’s anticipated medical

changes be accommodated in the requested Wheeled

Mobility Device?

The requested Wheeled Mobility Device can be modified to meet anticipated medical needs.

Other

The specified wheelchair frame can be modified since it is a modular frame. The seating components can be modified or additions can be made if/when the patient's medical status changes or to address wear and tear issues.

16. Caretaker Support: The individual has 24 Hour Care.

16a. Caretaker Support Hours per Day: 1 – 3 Hours Relationship/Role: 3 – 10 Hours

> 10 Hours

N/A16b. Amount of Time Alone per Day: 1 – 3 Hours

3 – 10 Hours

> 10 Hours

N/A

17. Additional Information:

N/A



*INDIVIDUAL’S Janie Doe *ID 000000000*18. List all Current/Previous DME:

DME TYPE, INCLUDING MANUFACTURER

AND MODEL

DATE OF PURCHA

SE(MM/YY)

ENVIRONMENTS WHERE USED (SELECT ALL THAT APPLY)

IS DME CURRENTLY

BEING USED?

IF INEFFECTIVE,PROVIDE REASON

SKILL LEVEL(CHECK ALL THAT APPLY)

18A. Rolling Walker 2009 Home YES unable to use since R CVA in 08/2013; was previously used at home

Independent

Guardian Work NO WNL endurance and distance School N/A Below normal endurance and distanceCommunity DependentSNF/ICF Other:

Comments, including special features (e.g.,

specialty seating components or

electronics):

Ownership: Personally Owned Other 18B. wheelchair >? 5 yrs

oldHome YES sizing is incorrect;

unable to provide adequate support since it lacks tilt-in-space feature

Independent

Drive Medical Tracer IV upright lightweight

Work NO WNL endurance and distance School N/A Below normal endurance and distanceCommunity DependentSNF/ICF Other:



electronics):

This therapist added seating components; however, frame modifications are not permitted by the nursing facility and the seating additions are inadequate to address her seating needs. It is not possible to address Ms. Simmon's postural needs in this wheelchair since she is unable to attain or sustain her trunk and head position without the assistance of gravity. A Geri-Recliner was trialed but was ineffective due to hamstring ROM musculature deficits.

Ownership: Personally Owned Other This wheelchair is owned by the nursing facility.18C. shower chair 2010 Home YES effective; used by

many residentsIndependent

Duralife tilt in space shower chair




electronics):

Ownership: Personally Owned Other This shower chair is owned by the nursing faciity. 18D. Home YES Independent




electronics):

Ownership: Personally Owned Other



*INDIVIDUAL’S Janie Doe *ID 00000000019. Functional Skills

ACTIVITY LEVEL OF INDEPENDENCE DME USED TO ADDRESS FUNCTIONAL TASK

COMMMENTS/FUNCTIONAL CONSIDERATIONS FOR REQUESTED DME:

Bathing Independent Mod Assistance Provide number from DME list on

page 3:

18c requires head and trunk postural components in tilted shower chairSupervision Max Assistance

Min Assistance Dependent

Dressing Independent Mod Assistance Provide number from DME list on

page 3:

Supervision Max Assistance


Grooming Independent Mod Assistance Provide number from DME list on

page 3:



Eating Independent Mod Assistance Provide number from DME list on

page 3:

18b G-Tube feedings; aspiration risks and precautions taken; in process of obtaining dysphagia assessment for possible oral feeding



Toileting Independent Mod Assistance Provide number from DME list on

page 3:



In-home mobility

Independent Mod Assistance Provide number from DME list on

page 3:

18b see comments 18bSupervision Max Assistance


20. Orthosis(es)/Prosthesis(es): NA / None

ITEM LEFT RIGHT BOTH EFFECTIVENESS COMMENTS/IF INEFFECTIVE, PLEASE EXPLAIN

Ankle Foot Orthosis(es)

Effective Ineffective

NA / None

Knee-Ankle-Foot Orthosis(es)


NA / None

Below Knee Prosthesis(es)


NA / None

Above Knee Prosthesis(es)


NA / None

TLSO N/A


NA / None

LSO N/A


NA / None

Other:


NA / None



*INDIVIDUAL’S Janie Doe *ID 00000000021. Transfer skills: Independent for all transfers Dependent for all transfers Varied transfer skills; see completed table

FROM TO METHOD LEVEL OF INDEPENDENCE EQUIPMENT

Bed Bed Stand pivot Independent NoneWheeled Mobility Device Wheeled Mobility Device 1 Person Lift Supervision Mechanical LiftChair Chair 2 Person Lift Min Assistance Ambulation AideHygiene Equipment Hygiene Equipment 2 persons

using mech. lift

Mod Assistance Sliding Boardfrom all locations to all locations Max Assistance

DependentBed Bed Stand pivot Independent NoneWheeled Mobility Device Wheeled Mobility Device 1 Person Lift Supervision Mechanical LiftChair Chair 2 Person Lift Min Assistance Ambulation AideHygiene Equipment Hygiene Equipment Mod Assistance Sliding Board Max Assistance



Dependent

22. Ambulation skills: Non-ambulatory on all surfaces Ambulatory on all surfaces Varied ambulation skills; see completed table

SURFACE AMBULATION STATUS SPEED DISTANCE ENDURANCE BALANCE SPECIFY AMBULATION AIDE

Carpet:

Ambulatory WNL < 10 ft < 5 min WNL N/ANon-Ambulatory Slow 10 – 30 ft 5 – 10 min Mild Impairment Fast 30 – 100 ft 10 – 30 min Mod Impairment

> 100 ft > 30 min Severe Impairment

Smooth:



Varied Terrain:


> 100 feet > 30 min Severe Impairment

Stairs:



23. Describe conditions which impact person’s ability to ambulate and/or transfer safely, independently, and in a timely manner; e.g., weakness, cardiovascular/respiratory compromise, ROM deficits, imbalance, tone, cognitive deficits, coordination, sensory deficits:

global weakness and tonal deficits, severe cognitive impairment



*INDIVIDUAL’S Janie Doe *ID 00000000024. Postural Control, Muscle Strength, and tone (Medical Research Council [MRC] Scale for Muscle Strength)

STRENGTH ( + ) / ( - ) ( + ) / ( - ) TONE COMMENTS

Trunk:

WNL (5) ( ) Trace (1) ( ) Hypotonia/Flaccid Rigidity anterior trunk flexion & R thoracic leaning; trunk rotation noted w/ L side posterior of R side

Good (4) ( ) Absent (0) ( ) Dystonia Mixed ToneFair (3) ( ) ( ) Spasticity Poor (2) ( )

Right Upper

Extremity:

WNL (5) ( ) Trace (1) ( ) Hypotonia/Flaccid Rigidity mild hypotoniaGood (4) ( ) Absent (0) ( ) Dystonia Mixed ToneFair (3) (+) ( ) Spasticity Poor (2) ( )

Left Upper Extremity:

WNL (5) ( ) Trace (1) ( ) Hypotonia/Flaccid Rigidity Good (4) ( ) Absent (0) ( ) Dystonia Mixed ToneFair (3) ( ) ( ) Spasticity Poor (2) ( )

Right Lower Extremity:

WNL (5) ( ) Trace (1) ( ) Hypotonia/Flaccid Rigidity intermittent clonus noted with positional changesGood (4) ( ) Absent (0) ( ) Dystonia Mixed Tone

Fair (3) (-) ( ) Spasticity Poor (2) ( )

Left Lower Extremity:


Head/Neck:


25. Postural Alignment of trunk, pelvis, neck, and lower extremities

POSTURAL ALIGNMENT FIXED VS. FLEXIBLE COMMENTS, INCLUDING QUANTITATIVE DATA

Trunk/Spine:Alignment WNL Lordosis Fixed high risk of fixed deformity

without adequate positioningScoliosis Rotation FlexibleKyphosis Mixed/Other

Pelvis/Hips:

Even Pelvic Obliquity Lower on Right Fixed tendency to sit with B LEs in position of abduction/external rotation for stability

Posterior Pelvic Tilt Pelvic Obliquity Lower On Left FlexibleAnterior Pelvic Tilt WNLRight Anterior Rotation Left Anterior Rotation

Head/Neck:

Normal Rotated Right Fixed left lateral neck tilt/flexion with rotation Tilted Left Anterior Flexible

Tilted Right Flat Lordotic CurveRotated Left

Leg Length:Even Discrepancy Fixed Flexible

Ankles/ Foot/Toes:

Even Pes Cavus Fixed B ankle hyperpronation (Right foot > left foot)Tibial Torsion Hyperpronation Flexible

Varus Heels Hallux ValgusValgus Heels Plantar-Flexed First RayPes Planus Hammer Toes

Other Pertinent

Information:

SEE ATTACHED PHOTOGRAPHS SUBMITTED THROUGH CLEAR COVERAGE



*INDIVIDUAL’S Janie Doe *ID 00000000026. Coordination, Motor Control, and Balance

ACTIVITY FUNCTIONAL SKILLS ACTIVITY COMMENTS/FUNCTIONAL SKILLS

Sitting Balance (Static):

Steady, safe

Standing (Static):

FunctionalLeans or slides UnsteadyUnable Steady, but uses wide stance and/or uses supportOther: leans to left side Narrow stance without support

Unable Other: requires 2 persons w/ L knee block

Upper Extremity

Gross Motor

Control:

Functional Upper Extremity

Fine Motor

Control:

FunctionalMild/moderate impairment Mild/moderate impairmentDependent DependentOther: Other:

27. Range of Motion (Optional – attach data)AREA AFFECTED RANGE OF MOTION LIMITATIONS RELATIVE TO SEATING COMMENTS/QUALIFYING INFORMATION

Right Upper Extremity: -10 degrees elbow extension pain with PROM (see attached ROM chart) Left Upper Extremity: -25 degrees elbow extension; -20 wrist extension pain with PROM (see attached ROM chart)

Right Lower Extremity: -10 degrees knee extension pain with PROM (see attached ROM chart) Left Lower Extremity: -25 degrees knee extension; -30 degrees hip extension pain with PROM (see attached ROM chart)

Head/Neck: WNL; tightness at end range in all planes pain with PROM (see attached ROM chart)28. Pain (Ref: www.painmed.org/SOPResources/ClinicalTools/government-websites/). Unable to determine if person is experiencing pain

LOCATION INTENSITY FREQUENCY DURATIONCOMMENTS/QUALIFYING

INFORMATION; RELATIONSHIP TO POSITIONING

None Upper Back 1 6 Occasional/Intermittent < 1 hour unable to determine intensity Right Upper Extremity Neck 2 7 Daily 1 – 3 hours Left Upper Extremity Lower Back 3 8 Chronic constant Right Lower Extremity Coccyx/Sacrum 4 9 N/A N/A Left Lower Extremity 5 10 None Upper Back 1 6 Occasional/Intermittent < 1 hour unable to determine intensity

yet facial grimaces are less with R UE and R LE

Right Upper Extremity Neck 2 7 Daily 1 – 3 hours Left Upper Extremity Lower Back 3 8 Chronic constant Right Lower Extremity Coccyx/Sacrum 4 9 N/A N/A Left Lower Extremity 5 10 None Upper Back 1 6 Occasional/Intermittent < 1 hour Right Upper Extremity Neck 2 7 Daily 1 – 3 hours Left Upper Extremity Lower Back 3 8 Chronic constant Right Lower Extremity Coccyx/Sacrum 4 9 N/A N/A Left Lower Extremity 5 10

29. Skin integrity (Optional: attach Braden Scale http://www.bradenscale.com/images/bradenscale.pdf)

CURRENT SKIN INTEGRITY STATUS HISTORY OF SKIN INTEGRITY RISK FACTORS

Intact Intact None

Impaired Impaired Impaired Nutritional StatusIf Impaired, date(s) of onset: If Impaired, date(s) of onset: 9/2013 Bony Prominences

If Impaired, stage: If Impaired, stage: 2 Fecal and/or Urinary IncontinenceIf Impaired, location(s): If Impaired, location(s): coccyx Circulatory Compromise

Ability to use pressure reducing methods:attempts to shift weight but is unsuccessful

Self-Positioning ImmobilityDecreased Self-Positioning Skills Sensory Deficits Non Self-Positioning Aged SkinOther If Sensory Deficits, indicate:


http://www.bradenscale.com/images/bradenscale.pdf

http://www.painmed.org/SOPResources/ClinicalTools/government-websites/


General Comments: lacks light touch sensation L LE and L UE responds to deep pressure

*INDIVIDUAL’S Janie Doe *ID 00000000030. Cardiovascular, Pulmonary, Vascular, Bowel and Bladder status

CONDITION CLINICAL OBSERVATIONS / REFERENCE TO DIAGNOSIS

Cardiac Status: Normal see diagnoses #14ImpairedUnable to Determine Status

Pulmonary Status: Normal ImpairedLack of Clinical Evidence to Determine Status

Vascular Status:Normal discoloration noted B LEs below mid-calves

which improves with tilted wheelchair Impaired

If Impaired, Edema

Grade Level:

1+ Barely detectible impression when finger pressed into skin improves with pillow under calves when in bed and with tilted wheelchair2+ Slight indentation: 15 seconds to rebound

3+ Deeper indentation: 30 seconds to rebound4+ >30 seconds to rebound

Bowel and Bladder Status:

Continent Bowel and Bladder Incontinent Bowel and Bladder

Catheterization: Yes No Suppository Use: Yes No

31. List the primary medical and functional objectives for the recommended wheeled mobility device, including how this will impact the individual’s ADL independence:

1) to improve pelvic stability and spinal/pelvic alignment2) to reduce loss of skin integrity risks3) to improve trunk and neck stability to begin oral feedings4) to decrease aspiration risks5) to decrease pain and improve sitting tolerance/endurance for OOB positioning

32. Describe the effectiveness of the trial simulation(s), including the person’s ability to utilize the recommended wheeled mobility device system within their customary environment(s), i.e., hallways, bedroom, bathroom, ramp, varied terrain. The following criteria/ information must be included reflecting the person’s cognitive, visual, safety, and fine and gross motor skills: (1) strength (2) endurance (3) range of motion (4) balance (5) risk factors considered, e.g., repetitive motion (6) location of trials (7) duration/frequency of trial(s) (8) ability to use controls; e.g., directionality, start/stop, special features; i.e., tilt, recline, power leg rests, seat elevator, power assist, one arm drive, tiller (9) need for additional training or caretaker assistance for drive controls. Indicate Dependent if applicable.

Ms. Doe will be dependent using the requested manaul wheelchair.

33. Are there anticipated changes in the individual’s customary environments with the next 1-2 years? If so, how was this taken into consideration for the requested wheeled mobility device?

No Yes, please explain:



The long term goal is for Ms. Doe to return home; however, the family is currently unwilling to consider this option. At that time, Money Follows the Person program will be considered. Although a power chair was considered and trialed, Ms. Doe lacks adequate cogntive and visual perceptual skills for effective and safe power chair use; i.e., severe left visual neglect, cognitive deficits, and lack of safety sense. If her visual perceptual, visual motor and cogntive status improves, a power chair will be re-evaluated.

*INDIVIDUAL’S Janie Doe *ID 00000000034. Explain/describe other medical approaches, functional strategies, other DME and/or alternative treatment(s), which were

considered and ruled out in lieu of using a wheeled mobility device.

See #18a & #33 regarding rollator ineffectiveness and results of power chair trial. In addition, the neurological evaluation 10/2013 (attached) reveal severe diffuse cerebral damage.

35. For residents of Skilled Nursing Facilities:

a. What is the length of time per day that the

wheeled mobility device will be used?

During the trial of loaner tilt-in-space wheelchair, Ms. Doe was able to tolerate wheelchair positioning ~9 hours per day (3 hours x3 daily), including each meal.

If this request is for a replacement wheeled mobility device under Sec. 17-134d-46 Customized Wheelchairs In Nursing Facilities Regulation, attach a copy of the current positioning program (required).

b. Describe the positioning program used to

address the individual’s needs, including the monitoring program.

This is not for a replacement wheelchair. She is rotated side-to-side in bed.

c. What is the person’s out of bed tolerance?

2-4 hrs/daily: She is currently out of bed for 2 meals daily (lunch and dinner), and in bed other times with a pillow under calves. Based upon her facial grimaces, she appears to be uncomfortable after 1-2 hours in an upright wheelchair.

36. Training to be provided to who/where/by whom for wheeled mobility use:

CLINICAL OBSERVATIONS / REFERENCE TO DIAGNOSIS

Request is for replacement Wheeled Mobility Device; therefore, the member has demonstrated proficient wheeled mobility skills PT/OT Training N/A: Individual is fully independent Other, please explain

Training will be provided by the evaluating OT to nursing staff regarding appropriate positioning in requested wheelchair, including medical precautions and associated clinical symptoms, and alternative positioning options. Based upon the results of the dysphagia evaluation, recommendations and training regarding neck position to be emphasized.

37. Comments (include e. g., Continued from #xx):



N/A

*INDIVIDUAL’S Janie Doe *ID 000000000Based on the clinical assessment and consideration of various Wheeled Mobility options, the following is suggested to address this person’s medical needs:

38. * Description of DME component:

This list can be pre-populated by the DME Provider. Postural components can be combined with hardware; e.g., lateral trunk pads with swing-away mounting hardware; phenolic upper extremity support with channel locks and strap.

39. Medical Rationale: Pre-populated, generic, and general rationales and definitions will not be accepted. Information must include: Document the rationale for requested base or component for this specific person, as

correlated with the documented clinical information. Reference comparisons and simulations; e.g., “Based upon trials of the seat cushions xx, yy, and zz, the zz cushion was chosen because….” Note: Only the essential components require comparison of various options, as related to the person’s medical condition.

If appropriate, include reason why a standard component would not address the person’s medical needs.

* Technical rationales can be written by the DME provider which should be designated with an asterisk. Include the reason the component is needed, as compared to less complex alternatives and correlated with necessary functional or technical outcomes.

a. *Solara 3G Tilt in Space (TS) wheelchair

She is unable to attain/sustain her trunk/head position without gravity assistance. A Geri-Recliner & upright wheelchair were trialed but were ineffective. Tilt-in-space (TS) is needed since for pressure relief and inhibit loss of skin integrity, and to maximize her sitting endurance/tolerance. Her neck position can be controlled in TS to inhibit aspiration risks. IRIS TS wheelchair seat height is too high for long-term Tx objective to increase transfer skills.

b. *flat free tires to maintain tire air pressure for safe transfers

c. *seat pan *Flush drop style seat plan chosen to decrease seat height without frame modifications which is the primary reason for choosing this wheelchair frame as compared to IRIS. Lower seat height needed to increase transfer skills. Base will support ROHO seat cushion.

d. *full length adjustable armrests for B UE weight bearing to optimize her trunk/neck control



e. *push button 2" pelvic positioner for pelvic stability and safety

f. *Elevating legrests (ELRs) with adjustable footplates; heel loops; padding on hangers; medial footblocks, calf panel; footplate extensions

ELRs aim to gradually increase LE ROM associated with ROM deficits in knees/hips as per B hamstring musculature hypertonia. Medial footblocks with heel loops provide placement cue for proper foot alignment. Padded hangers will protect skin due to sensory deficits. Footplate extensions needed to accommodate foot length. Custom calf panel needed to provide contoured & full weight bearing since she is intolerant of std flat pads with apparent pain.

g. *Matrix PB back with mounting hardware

-to provide posterior/ lateral contoured weight bearing and maximize weight bearing to increase sitting tolerance/endurance-to inhibit lateral thoracic trunk leaning-Planar/linear back was evaluated and found ineffective due to shape of body contact surface-Jay3 contoured back too shallow to accommodate kyphotic posture



*INDIVIDUAL’S Janie Doe *ID 000000000h. *High Profile ROHO seat cushion

with heavy duty, fluid resistant cover

-to offer high level of skin protection and comfort and sitting tolerance-to decrease likelihood loss of skin integrity due to documented risks-fluid resistant cover offer enhanced protection due to incontinence-Jay3 and ZeroG cushions trialed- found to be ineffective since posterior pelvic tilt increased

i. *Hip guides with L-bracket hardware

-to provide lateral pelvic guides to center her hips within the seating system to impede lateral trunk leaning/pelvic assymetry-brackets needed to attach to seat pan

j. *Half tray with elbow blocks, tray hardware

-for L UE weight bearing to maximize trunk alignment and decrease lateral/rotary tendencies -lateral and posterior elbow blocks are needed to prevent L UE from falling off tray when in tilted position and to also align UEs with shoulder girdle

k. *14' Plush headrest with LINX hardware

-to provide posterior head support due to poor neck/head control-to decrease aspiration risks-hardware mounts headrest to Matrx back support

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*INDIVIDUAL’S Janie Doe *ID 000000000r.

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*INDIVIDUAL’S Janie Doe *ID 000000000bb.

cc.

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I certify that I wrote this report and I am the Licensed Occupational and/or Physical Therapist identified below. I have included my credentials, affiliated agency, address, and contact information. My signature affirms that I personally wrote each section of this report, except where an asterisk is designated, based upon my own clinical knowledge, training and evaluation of the person’s medical condition.

Name: Mary Otherapist Credentials: MS, OTR CT License #: 00000

Agency: Superior Rehab Nursing Facility

Address L1: 000 Main Street

Address L2:

City: Anytown State: CT Zip Code: 00000

Phone Number: 000-000-0000 Fax Number:

0000000000 Email Address:

[email protected]

Electronic Signature Agreement. By clicking “I agree” and electronically signing below, you certify that: (1) you and the agency/facility in which you are employed agree to follow and are in compliance with the Connecticut Department of Social Services Conditions for DSS Acceptance of Electronic Signatures (“Electronic Signature Policy”) and (2) your electronic signature below complies with the Electronic Signature Policy. A handwritten signature is required for all other practitioners.

Signature: Mary Otherapist, MS, OTR Date (mm/dd/yyyy): 02/15/2014

Physician’s Signature: By signing below, I have reviewed and concur with the above evaluation:

Physician Agency: Internal Medicine Specialists, Inc

Physician NPI: 000000000

Electronic Signature Agreement. By clicking “I agree” and electronically signing below, you certify that: (1) you and the agency/facility in which you are employed agree to follow and are in compliance with the Connecticut Department of Social Services Conditions for DSS Acceptance of Electronic Signatures (“Electronic Signature Policy”) and (2) your electronic signature below complies with the Electronic Signature Policy. A handwritten signature is required for all other practitioners.

Signature: Johnnie A Doe, MD Date (mm/dd/yyyy): 02/17/2014


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