State of Oregon: LTCCN - Program Forms

Link	Additional Information	Date	Category
SDS 0753 Long Term Care Community Nursing Program Client Referral	Department required form for use by the LTC nurse to document and communicate information to the case manager. These forms are not intended to meet or replace documentation requirements set forth in Oregon nursing law and professional practice standards.	5/14/2018	Required form
SDS 4102 Prior Authorization form for APD LTCCN services	Department required form. Prior Authorization (Monitoring Visit, Teaching Non-Family, Teaching Family, Care Coordination and Reassessments). For use by the LTC nurse to document and communicate information to the case manager. These forms are not intended to meet or replace documentation requirements set forth in Oregon nursing law and professional practice standards.	3/19/2018	Required form
MSC 2099 Authorization for Use and Disclosure of Information	Business Forms that could be used by the LTC nurse to support business practices.	10/7/2017	Form
DHS189 Direct Deposit Authorization Instructions	Direct Deposit Authorization - Instructions Providers, Vendors and Contractors (Replaces DMAP 3077 and CF 134)	1/5/2016	Form
SDS 0752 APD LTC Community Nursing Services Summary	Department required form for use by the LTC nurse to document and communicate information to the case manager. These forms are not intended to meet or replace documentation requirements set forth in Oregon nursing law and professional practice standards	3/29/2013	Required form
SDS 0754 APD LTC Community Nursing Service Plan	Department required form for use by the LTC nurse to document and communicate information to the case manager. These forms are not intended to meet or replace documentation requirements set forth in Oregon nursing law and professional practice standards.	3/29/2013	Required form