Physician Summary Form 

Commonwealth of Massachusetts 
Executive Office of Health and Human Services 
www.mass.gov/masshealth 

This form verifies and validates the medical information provided by your patient or the patient’s legal guardian. This form must be returned as soon as possible. Without this information, your patient’s ability to initiate or continue to receive timely 
MassHealth services may be impacted. 
 
Patient
Last name
First name
Date of birth
Gender F  M

Diagnosis
Diagnosis(es)
Mental illness (indicate diagnosis):
Intellectual disability
Develpomental disability

Treatments
List type and frequency. 			

Medications (use back of form for additional medications) 
List drug, dose, route, and frequency.

Skilled Therapy
Direct therapy by OT, PT, ST

Recent vital signs
Date:
  T:
  P:
  R:
  BP:

Allergies
  No known allergies
  No known drug allergies
  Allergies list:

Height
Weight

Continence
Bowel
  Continent
  Incontinent
  Colostomy
Bladder
  Continent
  Incontinent
  Catheter

Mental Status
  Alert & oriented
  Alert & disoriented
  Other:

Recent Lab work
Diet:

Date of last physical exam
Date of last office visit

Additional comments/Special needs

I recommend this patient for the following service(s)
  Adult day health (ADH)
  Group adult foster care (GAFC)
  Adult foster care (AFC)
  Program for All-inclusive Care for the Elerly (PACE) 
  Nursing facility (NF) 
 
I certify that the information on this form, and any attached statement that I have provided has been reviewed and signed by me, and is true, accurate, and complete, 
to the best of my knowledge. I understand that I may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of any material 
fact contained herein. 

Provider’s signature  MD/NP/PA (Circle one.) 
(Signature and date stamps, or the signature of anyone other then the provider are not acceptable.) 
Print name: 
Date completed: 
Print address: 

PSF-1 (Rev. 07/10)