Part F, For Nursing Facility Applicants Only: if any of the questions are answered Yes, please complete and attach the full Level I screen (DHMH 4345).
Chronic Hospital/Special Hospital: vent dependent only (all other CH/SH use 3871).
Model Waiver: vent dependent only (all other MW use 3871).
Medical Adult Day Care: new applicants currently placed in a hospital or nursing facility only.
Cognitive Status (Part E): please answer Yes or No for EACH item.
Rehabilitation (PT/OT/Speech Therapy services): must be current ongoing treatment.
| Question | Answer |
|---|---|
| Form Name | DHMH 3871B |
| Form Length | 4 pages |
| Fillable? | Yes |
| Fillable fields | 150 |
| Avg. time to fill out | 25 min |
| Edition | 01/2016 |
| Who signs | Person Completing Form and Health Care Professional |
| Matches the agency's file | Yes, checked October 2, 2026 |
| Other names | DHMH 3871B, DHMH3871B, DHMH-3871B, 3871B, 3871B form, Maryland 3871B, Medical Eligibility Review Form #3871B |
| Official source | DHMH 3871B (Rev 01/2016), |
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