When navigating the complex landscape of healthcare and Medicaid eligibility in Georgia, the Georgia DMA 6 form emerges as a critical document, especially for children requiring pediatric care. This form is utilized across various programs such as Nursing Facility, GAPP, TEFRA/Katie Beckett, and PEDIATRIC care, underscoring its versatility and importance in the healthcare process. Its primary function is to gather comprehensive information regarding the applicant, which includes identifying details like the Medicaid number and social security, as well as a thorough physician’s recommendation for pediatric care. The form meticulously details the applicant's medical history, diagnosis, treatment plan, and the recommended level of care, whether it be a hospital, nursing facility, or IC/MR facility. Additionally, it assesses the necessity for specialized care through an evaluation of nursing care needed, covering aspects from nutrition and mobility to the neurological status of the child. The form accomplishes more than just a medical assessment; it authorizes the release of medical records to relevant departments, facilitating the process of Medicaid eligibility determination. With provisions for documenting previous hospitalizations, current health services, anticipated hospitalization dates, and even the status of communicable diseases, the Georgia DMA 6 form is a comprehensive tool designed to ensure that pediatric patients receive the appropriate level of care for their condition while also considering the potential for community or home health services as alternatives to institutionalization.
Question | Answer |
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Form Name | Georgia Dma 6 Form |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | dma 526 form ga, dma6, dma 6 form georgia, gammis dma 6 form |
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Type of Program: |
Nursing Facility |
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GAPP |
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TEFRA/Katie Beckett |
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PEDIATRIC DMA 6(A) |
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PHYSICIAN’S RECOMMENDATION FOR PEDIATRIC CARE |
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Section A – Identifying Information |
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1. |
Applicant’s Name/Address: |
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Medicaid Number: |
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3. Social Security Number |
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4. Sex |
Age |
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4A. Birthdate |
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DFCS County_____________________ |
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5. |
Primary Care Physician |
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___________________________________________ |
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6. |
Applicant’s Telephone # |
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Mailing Address |
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7. |
Does guardian think the applicant should be institutionalized? |
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8. |
Does child attend school? |
9. Date of Medicaid Application |
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No |
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No |
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Name of Caregiver #1: _______________________________ |
Name of Caregiver #2: ______________________________ |
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I hereby authorize the physician, facility or other health care provider named herein to disclose protected health information and release the medical records of the applicant/beneficiary to the Department of Community Health and the Department of Human Resources, as may be requested by those agencies, for the purpose of Medicaid eligibility determination. This authorization expires twelve (12) months from the date signed or when revoked by me, whichever comes first.
10. Signature:___________________________________________________________________ |
11. Date:__________________________ |
(Parent or other Legal Representative) |
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Section B – Physician’s Report and Recommendation
12. |
History: (ATTACH ADDITIONAL SHEET IF NEEDED) |
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1. ICD |
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2. ICD |
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3. ICD |
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13. |
Diagnosis |
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1)_______________________________ 2)_______________________________ 3)_____________________________ |
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(Add attachment for additional diagnoses) |
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14. |
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Medications |
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15. |
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Diagnostic and Treatment Procedures |
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Name |
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Dosage |
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Route |
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Frequency |
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Type |
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Frequency |
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16. |
Treatment Plan (Attach copy of order sheet if more convenient or other pertinent documents) |
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Previous Hospitalizations:____________________________ Rehabilitative Services:__________________________ Other Health Services:_________________________ |
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Hospital Diagnosis: 1)_________________________________ 2) Secondary______________________________ 3) Other_____________________________________ |
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17. Anticipated Dates of Hospitalization: |
__________/________ |
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18. |
Level of Care Recommended: |
Hospital |
Nursing Facility |
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IC/MR Facility |
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19. |
Type of Recommendation: |
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20. Patient Transferred from (check one): |
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21. Length of Time Care Needed _____Months |
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22. Is patient free of |
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Initial |
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Hospital |
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Another NF |
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1) |
Permanent |
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communicable diseases? |
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Change Level of Care |
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Private Pay |
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Lives at home |
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2) |
Temporary _______ estimated |
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Yes |
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No |
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Continued Placement |
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23. |
This patient’s condition |
could |
could not be managed by |
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24. Physician’s Name (Print): |
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provision of |
Community Care or |
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Home Health Services |
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Physician’s Address (Print): |
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25. |
I certify that this patient requires the level of care provided |
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26. Date signed by Physician |
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27. |
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Physician’s Licensure No. |
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28. Physician’s Telephone #: |
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by a nursing facility, IC/MR facility, or hospital |
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( |
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______________________________________Physician’s Signature |
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Section C– Evaluation of Nursing Care Needed (check appropriate box only) |
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29. |
Nutrition |
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30. |
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Bowel |
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31. Cardiopulmonary Status |
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32. |
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Mobility |
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33. |
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Behavioral Status |
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Regular |
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Age Dependent |
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Monitoring |
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Prosthesis |
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Agitated |
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Diabetic Shots |
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Incontinence |
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Splints |
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Cooperative |
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Incontinent - Age > 3 years |
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CP Monitor |
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Unable to ambulate > |
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Alert |
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Tube feeding |
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Colostomy |
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Pulse Ox |
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18 months old |
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Developmental Delay |
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Continent |
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Vital signs > 2/days |
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Wheel chair |
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Mental Retardation |
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Slow Feeder |
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Other ________________ |
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Therapy |
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Normal |
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Behavioral Problems |
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FTT or Premature |
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Oxygen |
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(please describe, if checked) |
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Hyperal |
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Home Vent |
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Suicidal |
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IV Use |
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Trach |
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Hostile |
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Medications/GT |
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Nebulizer Tx |
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Meds |
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Suctioning |
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Chest - Physical Tx |
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Room Air |
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34. |
Integument System |
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35. |
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Urogenital |
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36. |
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Surgery |
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37. |
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Therapy/Visits |
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38. |
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Neurological Status |
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Burn Care |
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Dialysis in home |
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Level 1 (5 or > surgeries) |
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Day care Services |
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Deaf |
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Sterile Dressings |
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Ostomy |
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Level II (< 5 surgeries) |
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High Tech - 4 or more |
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Blind |
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Decubiti |
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Incontinent – Age > 3 years |
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None |
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times per week |
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Seizures |
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Bedridden |
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Catheterization |
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Low Tech – 3 or less times |
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Neurological Deficits |
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Continent |
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per week or MD visits > 4 |
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Paralysis |
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Normal |
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per month |
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Normal |
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None |
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39. |
Other Therapy Visits |
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40. |
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Remarks |
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Five days per week |
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Less than 5 days per week |
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41. |
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42. |
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Date Signed |
43. Print Name of MD or RN:_____________________________ |
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Signature of MD or RN:_______________________________ |
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DO NOT WRITE BELOW THIS LINE |
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44. |
Continued Stay Review Date: |
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Admission Date ___________________ Approved for ______________Days or ___________Months |
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45. |
Are nursing services, rehabilitative services or other health related services |
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46A. State Authority MH & MR Screening) |
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requested ordinarily provided in an institution? |
Yes |
No |
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Level I/II |
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Restricted Auth. Code |
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Date |
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46B. This is not a |
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47. |
Hospitalization Precertification |
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Met |
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Not |
Met |
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Restricted Auth. Code |
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Date |
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48. |
Level of Care Recommended by Contractor |
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Hospital |
Nursing Facility |
IC/MR Facility |
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49. |
Approval Period |
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50. Signature (Contractor) |
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51. Date |
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52. Attachments (Contractor) |
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________________ |
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/ |
/ |
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Yes |
No |
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