Dhmh 3871B Form PDF Details

Did you know that there is a form to fill out in order to get dhmh 3871B? If you are not familiar with what this is, it is the Disability Housing and Supportive Services Program Application. This program can provide affordable and accessible housing for people who have a disability. In order to be eligible for this program, there are certain criteria that you must meet. You can find more information about the DHMH 3871B form and the eligibility requirements on our website. We also have a helpful FAQ section where you can find answers to commonly asked questions. So if you are interested in applying for the DHMH 3871B form, be sure to check out our website!

QuestionAnswer
Form NameDhmh 3871B Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other names3871b instructions printable, 3871b medical review print, maryland 3871b, md 3871b

Form Preview Example

Maryland Medical Assistance

Medical Eligibility Review Form #3871B

Part A – Service Requested

1. Requested Eligibility Date:

 

 

 

2. Admission Date

 

3. Facility MA Provider #:

_________________________

 

 

 

 

_____________________

____________________________

4. Check Service Type Below:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nursing Facility

 

 

 

Medical Day Care Waiver

 

 

Waiver for Older Adults

 

 

 

 

 

 

 

 

 

 

 

 

 

Living at Home Waiver

 

 

 

PACE

 

 

Model Waiver vent only dependent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(all other MW use 3871)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chronic Hospital vent dependent only (all other CH use 3871)

 

 

 

 

 

 

 

 

 

 

 

 

 

5. Check Type of Request

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Initial

 

 

 

 

Conversion to MA (NF)

 

 

Medicare ended (NF)

 

 

 

MCO disenrollment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(NF)

 

 

 

 

Readmission – bed

 

 

 

Transfer new provider

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Update expired LOC

 

 

 

Corrected Date

 

 

 

 

 

 

 

 

 

 

 

 

 

reservation exp. (NF)

 

 

 

(NF)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Significant change from

 

 

Recertification

 

Advisory (please include payment)

 

 

 

 

 

 

 

 

 

 

previously denied request

 

 

 

 

(Waivers/PACE only)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part B – Demographics

1. Client Name: Last ________________________First ______________________ MI _____ Sex: M

 

 

F

SS# ______- ____- _______

MA # __________________________ DOB __________

 

2. Current Address (check one):

 

Facility

 

Home

 

 

 

 

 

 

 

Address 1 ___________________________________________________________________________

Address 2 ___________________________________________________________________________

City __________________________ State _______ ZIP _____________ Phone ___________________

If placed in facility, name of facility ______________________________________________________

If in acute hospital, name of hospital_______________________________________________________

3.Next of Kin/ Representative

Last name _________________________ First Name _______________________ MI _____

Address 1 ____________________________________________________________________________

Address 2 ___________________________________________________________________________

City ___________________________ State _________ ZIP ___________ Phone __________________

4.Attending Physician

Last name _________________________ First Name _______________________ MI _____

Address 1 ___________________________________________________________________________

Address 2 ___________________________________________________________________________

City ____________________________ State _________ ZIP ___________ Phone _________________

DHMH Form #3871B

 

Rev 10/11

Page 1 of 4

Applicant Name ____________________________

Part C – MR/MI Please Complete the Following on All Individuals:

 

 

 

 

 

 

 

 

 

Review Item

 

 

 

 

 

Answer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y

 

N

1.

Is there a diagnosis or presenting evidence of mental retardation/related condition, or has the client received

 

 

 

 

 

 

 

 

 

 

 

 

 

MR services within the past two years?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Is there any presenting evidence of mental illness?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please note: Dementia/Alzheimer’s is not considered a mental illness.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. If yes, check all that apply.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Schizophrenia

 

 

 

Personality disorder

 

 

Somatoform disorder

 

Panic or severe anxiety disorder

 

 

 

 

 

 

 

 

 

 

 

 

Mood disorder

 

 

Paranoia

 

 

Other psychotic or mental disorder leading to chronic disability

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. Has the client received inpatient services for mental illness within the past two years?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

Is the client on any medication for the treatment of a major mental illness or psychiatric diagnosis?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. If yes, is the mental illness or psychiatric diagnosis controlled with medication?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

Is the client a danger to self or others?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part D – Diagnoses

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary diagnosis related to the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

need for requested level of care

 

ICD Code

 

 

Description

 

 

 

 

 

 

Other active diagnoses related to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

the need for requested level of care

 

Descriptions

 

 

 

 

 

 

 

 

 

 

 

Part E – Skilled Services:

Requires a physician’s order. Requires the skills of technical or professional personnel such as a registered nurse, licensed practical nurse, respiratory therapist, physical therapist, and/or occupational therapist. The service must be inherently complex such that it can be safely and effectively performed only by, or under the supervision of, professional or technical personnel. Items listed under Rehabilitation and Extensive Services may overlap.

Table I. Extensive Services (serious/unstable medical condition and need for service)

 

Review Item

 

# of days service is

 

(Please indicate the number of days per week each service is required)

 

required/wk. (0-7)

 

 

 

1.

Tracheotomy Care: All or part of the day

 

 

 

 

 

 

2.

Suctioning: Not including routine oral-pharyngeal suctioning, at least once a day

 

 

 

 

 

 

3.

IV Therapy: Peripheral or central (not including self-administration)

 

 

 

 

 

 

4.

IM/SC Injections: At least once a day (not including self-administration)

 

 

 

 

 

 

5.

Pressure Ulcer Care: Stage 3 or 4 and one or more skin treatments (including pressure-

 

 

relieving bed, nutrition or hydration intervention, application of dressing and/or medications)

 

 

 

 

6. Wound Care: Surgical wounds or open lesions with one or more skin treatments per day (e.g.,

 

application of a dressing and/or medications daily)

 

 

 

 

 

 

7.

Tube Feedings: 51% or more of total calories or 500 cc or more per day fluid intake via tube

 

 

8.

Ventilator Care: Individual would be on a ventilator all or part of the day

 

 

 

 

 

 

9.

Complex respiratory services: Excluding aerosol therapy, spirometry, postural drainage or

 

 

routine continuous O2 usage

 

 

 

 

 

10. Parenteral Feeding or TPN: Necessary for providing main source of nutrition.

 

 

 

 

 

11. Catheter Care: Not routine foley

 

 

 

 

 

12. Ostomy Care: New

 

 

 

 

 

DHMH Form #3871B

 

 

Rev 10/11

Page 2 of 4

Applicant Name ____________________________

13.Monitor Machine: For example, apnea or bradycardia

14.Formal Teaching/Training Program: Teach client or caregiver how to manage the treatment regime or perform self care or treatment skills for recently diagnosed conditions (must be ordered by a physician)

Table II. Rehabilitation (PT/OT/Speech Therapy services) Must be current ongoing treatment.

Review Item

No. of days service

(Please indicate the number of days per week each service is required.

is required/wk.

 

(0-7)

15.Extensive Training for ADLs. (restoration, not maintenance), including walking, transferring, swallowing, eating, dressing and grooming.

16.Amputation/Prosthesis Care Training: For new amputation.

17.Communication Training: For new diagnosis affecting ability to communicate.

18.Bowel and/or Bladder Retraining Program: Not including routine toileting schedule.

Part F – Functional Assessment

Review Item

Answer

Cognitive Status (Please answer Yes or No for EACH item.)

Y

 

N

1. Orientation to Person: Client is able to state his/her name.

 

 

 

 

2.Medication Management: Able to administer the correct medication in the correct dosage, at the correct frequency without the assistance or supervision of another person.

3.Telephone Utilization: Able to acquire telephone numbers, place calls, and receive calls without the assistance or supervision of another person.

4.Money Management: Can manage banking activity, bill paying, writing checks, handling cash transactions, and making change without the assistance or supervision of another person.

5.Housekeeping: Can perform the minimum of washing dishes, making bed, dusting, and laundry, straightening up without the assistance or supervision of another person.

6. Brief Interview for Mental Status (BIMS): Was the examiner able to administer the complete interview? If yes, indicate the final score. If no, indicate reason.

 

If yes, Score: ____________

(Examination should be administered in a language in which the client is fluent.)

If No, check one of the following:

 

 

 

 

 

 

 

Hearing Loss

 

 

 

 

Applicant is rarely/never understood

 

 

 

 

 

 

 

Language Barrier

 

 

 

Refused

 

 

 

 

 

 

Other

 

 

 

(specify) ______________________

Behavior (Please answer Yes or No for EACH item.)

Answer

 

Y N

7.Wanders (several times a day): Moves with no rational purpose or orientation, seemingly oblivious to needs or safety.

8.Hallucinations or Delusions (at least weekly): Seeing or hearing nonexistent objects or people, or a persistent false psychotic belief regarding the self, people, or objects outside of self.

9.Aggressive/abusive behavior (several times a week): Physical and verbal attacks on others including

but not limited to threatening others, hitting, shoving , scratching, punching, pushing, biting, pulling hair or destroying property.

10.Disruptive/socially inappropriate behavior (several times a week): Interferes with activities of others or own activities through behaviors including but not limited to making disruptive sounds, self- abusive acts, inappropriate sexual behavior, disrobing in public, smearing/throwing food/feces, hoarding, rummaging through other’s belongings, constantly demanding attention, urinating in inappropriate places.

11.Self-injurious behavior (several times a month): Repeated behaviors that cause injury to self, biting, scratching, picking behaviors, putting inappropriate object into any body cavity, (including ear, mouth, or nose), head slapping or banging.

DHMH Form #3871B

 

Rev 10/11

Page 3 of 4

Applicant Name ____________________________

 

 

Answer

Communication (Please answer Yes or No for EACH item.)

 

Y

 

N

12. Hearing Impaired even with use of hearing aid: Difficulty hearing when not in quiet setting,

 

 

 

 

 

understands conversations only when face to face (lip-reading), can hear only very loud voice or totally

 

 

 

 

 

deaf.

 

 

 

 

 

13.Vision Impaired even with correction: Difficulty with focus at close range, field of vision is severely limited (tunnel vision or central vision loss), only sees light, motion, colors or shapes, or is totally blind.

14.Self Expression: Unable to express information and make self understood using any means (with the exception of language barrier).

Review Item

FUNCTIONAL STATUS: Score as Follows

 

0

= Independent: No assistance or oversight required

 

1

= Supervision: Verbal cueing, oversight, encouragement

 

2

= Limited assistance: Requires hands on physical assistance

Score Each Item

3

= Extensive assistance: Requires full performance (physical assistance and verbal cueing) by

(0-4)

another for more than half of the activity.

 

4

= Total care: Full activity done by another

 

15.Mobility: Purposeful mobility with or without assistive devices.

16.Transferring: The act of getting in and out of bed, chair, or wheelchair. Also, transferring to and from toileting, tub and/or shower.

17.Bathing (or showering): Running the water, washing and drying all parts of the body, including hair and face.

18.Dressing: The act of laying out clothes, putting on and removing clothing, fastening of clothing and footwear, includes prostheses, orthotics, belts, pullovers.

19.Eating: The process of putting foods and fluids into the digestive system (including tube feeding).

20.Toileting: Ability to care for body functions involving bowel and bladder activity, adjusting clothes, wiping, flushing of waste, use of bedpan or urinal, and management of any special devices (ostomy or catheter). This does not include transferring (See transferring item 16 above).

CONTINENCE STATUS: Score as Follows

0 = Independent: Totally continent, can request assistance in advance of need, accidents only once or twice a week or is able to completely care for ostomy.

1 = Dependent: Totally incontinent, accidents three or more times a week, unable to request

Score Each Item

assistance in advance of need, continence maintained on toileting schedule, indwelling, suprapubic

(0-1)

or Texas catheter in use or unable to care for own ostomy.

 

21.Bladder Continence: Ability to voluntarily control the release of urine from the bladder

22.Bowel Continence: Ability to voluntarily control the discharge of stool from the bowel.

Part G – Certification

1.Signature of Person Completing Form: _____________________________________ Date________________

Printed Name________________________________________

I certify to the best of my knowledge the information on the form is correct.

2.Signature of Health Care Professional: ______________________________________ Date________________

Printed Name_______________________________________

DHMH Form #3871B

 

Rev 10/11

Page 4 of 4

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maryland 3871b writing process described (stage 1)

2. Just after filling out this section, go to the subsequent step and enter all required particulars in all these blanks - Current Address check one, Address, Address, City State ZIP Phone, If placed in facility name of, If in acute hospital name of, Next of Kin Representative, Last name First Name MI, Address, Address, City State ZIP Phone, Attending Physician, Last name First Name MI, Address, and Address.

Tips on how to complete maryland 3871b portion 2

Lots of people frequently make errors when filling out If placed in facility name of in this area. You should definitely review whatever you enter right here.

3. This next step will be focused on Applicant Name, Part C MRMI Please Complete the, Review Item, Is there a diagnosis or, Answer Y N, Mood disorder Paranoia Other, Has the client received inpatient, Is the client on any medication, a If yes is the mental illness or, Is the client a danger to self or, Part D Diagnoses Primary, ICD Code, and Description - complete all these blank fields.

Step # 3 of submitting maryland 3871b

4. This next section requires some additional information. Ensure you complete all the necessary fields - Review Item, Please indicate the number of days, Tracheotomy Care All or part of, Suctioning Not including routine, IV Therapy Peripheral or central, IMSC Injections At least once a, Pressure Ulcer Care Stage or, Wound Care Surgical wounds or, Tube Feedings or more of total, Complex respiratory services, Parenteral Feeding or TPN, Catheter Care Not routine foley, Ostomy Care New, and of days service is requiredwk - to proceed further in your process!

maryland 3871b writing process explained (portion 4)

5. To finish your form, this final area includes some additional fields. Entering Applicant Name, Monitor Machine For example apnea, Formal TeachingTraining Program, Table II Rehabilitation PTOTSpeech, Please indicate the number of days, Review Item, No of days service, is requiredwk, Extensive Training for ADLs, Part F Functional Assessment, Review Item Cognitive Status, and Answer N Y is going to conclude the process and you'll definitely be done in no time!

Table II Rehabilitation PTOTSpeech, Monitor Machine For example apnea, and Part F  Functional Assessment inside maryland 3871b

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