3871 Maryland Medicaid Form – Fill Out and Use This PDF

Maryland Medical Assistance Program

Medical Eligibility Review Form PLEASE PRINT OR TYPE

Level of Care/Services Requested (application for rehab			Application date: ______________________
hospitals must be accompanied by a plan of care from admitting			Financial Eligibility Date: ________________
hospital) (Please check)			Social Security #: ______________________
NF	Medical Day Care	Rehab Hospital	Medical Assistance #: __________________________
Chronic	Other
Hospital	(e.g. Waiver)	___________________

Part A: Patient Demographics

Patient’s Last Name: ___________________________________	Patients First Name: __________________________
Patients Date of Birth: ________Sex_____ Adm. Date_________	Verbal level of care given (LOC):_________________
Permanent Address: ____________________________________	__________ by_____________________________
	Date	Utilization Control Agent
_______________________________________________________________________	Name of Last Provider (Hospital, Long Term Care Facility)
Present location of Patient: (if different from above)	Institution: _____________________________________
_________________________________________________________	Admission Date: _________________________________
_________________________________________________________	Discharge Date: _________________________________
Patients Representative Name: _______________________________	Relationship to Patient: ___________________________
Representative Phone # _____________________________________	Representative Address: __________________________
Is language a barrier to communication ability? ___ YES ___ NO	______________________________________________

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Part B: Physician’s Plan of Care (Must be completed by physicians or designee)

Please fill out accurately and completely

Physicians Name: __________________________ Telephone #: ___________________ Address: _________________________

Primary Diagnoses which relate to need for level of care: __________________________________________________________

Secondary/Surgical Diagnoses currently requiring M.D and/or Nursing intervention which relates to level of care:

__________________________________________________________________________________________ Date: __________

__________________________________________________________________________________________ Date: __________

Other pertinent findings (ex. Signs and symptoms, complications, lab results, etc… ______________________________________

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

_____________________________________________________________________________________________

Is patient free from infection TB? ___ YES ___ NO Determined by: ___ Chest X-Ray ___ PPD Date: ______________________

T __________ P __________ R __________ B/P __________ HT ____________ WT __________

Have any of the above vital signs undergone a significant change? ___ YES ___ NO If yes explain: ________________________

_________________________________________________________________________________________________________

Diet (Include supplements and tubefeeding solution) _____________________________________________________________

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Medical Review Form

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Patients Name: ___________________________________

Medication which will be Continued:

Treatment which will Be Continued: DescriptionFrequencyDuration if Temporary

___ Ventilator: ____________________________________________________________________________________________

___ 02 (as well as sats and frequency): _________________________________________________________________________

___ Monitor (apnea/bradycardia (A/B), other: ___________________________________________________________________

___Suctioning: _____________________________________________________________________________________________

___ Trach Care: ____________________________________________________________________________________________

___ IV Line/fluids (indicate central or peripheral): ________________________________________________________________

___ Tube feeding (specify type of tube): ________________________________________________________________________

___ Colostomy/ileostomy care: _______________________________________________________________________________

___ Catheter/continence device (specify type): __________________________________________________________________

___ Frequent labs related to nutrition/needs (describe): ___________________________________________________________

___ Decubitus (include size, location, stage, drainage, and signs of infection, also Tx regimen): ____________________________

_________________________________________________________________________________________________________

___ Other (specify): ________________________________________________________________________________________

_________________________________________________________________________________________________________

Have any medications or treatments recently been implemented, discontinued, and/or otherwise changed? Explain:

_______________________________________________________________________________________________________________

___________________________________________________________________________________________________

Impairments/devices (check all that apply) ___Speech ___ Sight ___Hearing ___ Other (specify) ___________________________

___ Devices/Adaptive Equipment _____________________________________________________________________________

Active Therapy	Plan	Frequency	Est. Duration	Goal
Physical Therapy
Occupational Therapy
Speech Therapy
Respiratory
Others

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Patients Name: ___________________________________

Rehabilitation Potential: _____________________________________________________________________________________

Discharge Plan: ____________________________________________________________________________________________

*If requesting a level of care for rehab hospital, please answer the following questions:

1.Preexisting condition related to current physical, behavioral and mental functions and deficits: _________________________

_________________________________________________________________________________________________________

2.Reason for out-of-state placement (if applicable): ______________________________________________________________

Is Patient Comatose? ___ YES ___ NO if yes skip parts C through E and go directly to part F.

PLEASE NOTE: For other adults applicants, complete parts C and D, skip E. For applicants under age 21, skip Parts C and D, complete E.

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	Part C: Functional Status (Use one of the following codes)
	(if assistive device (e.g., Wheelchair, walker) used, note functional ability while using device)
0.	Little or no difficulty (completely independent	2.	Limited physical assistance by caregiver
	or setup only is needed	3.	Extensive physical assistance by caregiver
1.	Supervision/Verbal cuing	4.	Total dependence on others
___ Locomotion (if using adaptive/assistive device,		___ Dressing
Specify type: ______________________________		___ Bathing
___ Transfer bed/chair		___ Eating
___ Reposition/Bed Mobility		Appetite (check one): ___Good ___Fair ___ Poor

Other Functional limitations (describe) _________________________________________________________________________

Incontinence management (Circle applicable choices in each category) (Note status with toileting program and/or continence device, if applicable)

Bladder	Bowel
0	0	Complete control-or infrequent stress incontinence
1	1	Usually continent-accidents once a week or less
2	2	Occasionally incontinent-accidents 2+ weekly, but not daily
3	3	Frequently incontinent- accidents daily but some control present
4	4	Incontinent- Multiple daily accidents

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3. Communication	0-Always,	1-Usually,	2-Sometimes,	3-Rarely
Ability to understand others	_____	_____	_____	_____
Ability to make self understood	_____	_____	_____	_____
Ability to follow simple commands	_____	_____	_____	_____

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Medical Review Form

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Patients Name: ___________________________________

4. Behavior issues (enter one code from A and B in the appropriate column)

5. Most recent mini-mental score _________________________ Date: ___________________

Previous mini-mental score (if available) _______________________ Date: ________________

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Part E: Functional/Cognitive Status – Pediatric

	Age Appropriate		Functioning level	Adaptive Equipment
Cognition				Wheelchair
Social/Emotional				Splints/Braces
Behavior				Side Lyer
Communications				Walker
Gross Motor Abilities				Adaptive Seating
Fine Motor Abilities				Communication devices
Feeding				Other
Toileting
Self Care
		Part F: Physician’s Certification for Level of Care

This patient is certified as in need of the following services (check one):

Other information pertinent to need for Long Term Care: ____________________________________________________________

Physicians Signature: ____________________________________________________________ Date: ________________________

Other than physician completing form: ___________________________________________________________________________

Signature

Title

Phone

Date

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This area is for Agent Determination Only. Do Not write in this area.

		Renewal
___ Medical Eligibility Established	MD Advisor ___	___ Medical Eligibility Established	MD Advisor ___
___ Medical Eligibility Denied		___ Medical Eligibility Denied
Effective Date: _________________		Effective Date: _________________
Type of Service: ___________________________________		Type of Service: ___________________________________
Certificate Period: From: _____________ To: ____________		Certificate Period: From: _____________ To: ____________
Agent Signature: __________________________________		Agent Signature: __________________________________
Date: _______________________		Date: _______________________

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Medical Review Form

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