Form DMA 6A – Fill Out and Use This PDF

The DMA 6A form is a Georgia Medicaid document that a licensed physician completes to recommend pediatric medical care. Physicians use it to record diagnoses, functional limitations, medications, and treatment needs for a child. The form supports decisions about nursing facility care, intermediate care facilities, or community-based services. Georgia Medicaid relies on this information to confirm medical necessity, determine eligibility, and decide whether a child needs institutional care or can safely receive services in the community.

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Georgia DMA 6A Form PDF Details

In addition to basic medical information, families and providers often use the DMA 6A form for the TEFRA/Katie Beckett program. It helps show that a child meets an institutional level of care while continuing to live at home. That distinction matters because TEFRA looks at medical need, not family income.

Physicians use the DMA 6A to explain how much care a child needs each day, what type of skilled support is required, and what could happen if services stop.

The DMA-6A form asks the physician to describe the child’s real-life care needs. Doctors explain whether the child needs hands-on nursing care, constant supervision, medical equipment, or frequent treatments. Medicaid reviewers read these details closely to understand how the child functions outside a hospital or facility. Families often submit the Pediatric DMA 6(A) form for new TEFRA applications, renewals, or when a child’s condition changes.

The DMA 6A form commonly covers:
• Level of medical supervision the child needs,
• Skilled nursing tasks and how often they occur,
• Dependence on caregivers for daily activities,
• Medications, therapies, and equipment in use,
• Risk of hospitalization or placement in a facility.

Note! The DMA 6A form is often confused with the Georgia DMA 6 form. DMA 6 applies to adults and nursing facility placement, while DMA 6A is only for children and supports pediatric Medicaid programs like TEFRA.

Question	Answer
Form Name	Form DMA 6A Georgia
Form Length	1 pages
Fillable?	Yes
Fillable fields	155
Avg. time to fill out	20 min
Other names	dma-6a form, pediatric dma 6(a) form, Georgia dma 6a, physician recommendation for pediatric care form

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						Type of Program:	Nursing Facility
							GAPP
							TEFRA/Katie Beckett
			PEDIATRIC DMA 6(A)
		PHYSICIAN’S RECOMMENDATION FOR PEDIATRIC CARE
Section A – Identifying Information
1.	Applicant’s Name/Address:			2.	Medicaid Number:		3. Social Security Number

							4. Sex	Age		4A. Birthdate
					----------------------------------------
	DFCS County_____________________
	DFCS County_____________________			5.	Primary Care Physician
				5.	Primary Care Physician
	___________________________________________
	___________________________________________			6.	Applicant’s Telephone #
	Mailing Address			6.	Applicant’s Telephone #
	Mailing Address
7.	Does guardian think the applicant should be institutionalized?			8.	Does child attend school?		9. Date of Medicaid Application
	Yes	No			Yes	No		/	/
Name of Caregiver #1: _______________________________			Name of Caregiver #2: ______________________________

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)

Section B – Physician’s Report and Recommendation

12.

History: (ATTACH ADDITIONAL SHEET IF NEEDED)

1. ICD

2. ICD

3. ICD

13.

Diagnosis

1)_______________________________ 2)_______________________________ 3)_____________________________

(Add attachment for additional diagnoses)

14.

Medications

15.

Diagnostic and Treatment Procedures

Name

Dosage

Route

Frequency

Type

Frequency

16.

Treatment Plan (Attach copy of order sheet if more convenient or other pertinent documents)

Previous Hospitalizations:____________________________ Rehabilitative Services:__________________________ Other Health Services:_________________________

Hospital Diagnosis: 1)_________________________________ 2) Secondary______________________________ 3) Other_____________________________________

17. Anticipated Dates of Hospitalization:

__________/________

18.

Level of Care Recommended:

Hospital

Nursing Facility

IC/MR Facility

19.

Type of Recommendation:

20. Patient Transferred from (check one):

21. Length of Time Care Needed _____Months

22. Is patient free of

Initial

Hospital

Another NF

Permanent

communicable diseases?

Change Level of Care

Private Pay

Lives at home

Temporary _______ estimated

Yes

Continued Placement

23.

This patient’s condition

could

could not be managed by

24. Physician’s Name (Print):

provision of

Community Care or

Home Health Services

Physician’s Address (Print):

25.

I certify that this patient requires the level of care provided

26. Date signed by Physician

27.

Physician’s Licensure No.

28. Physician’s Telephone #:

by a nursing facility, IC/MR facility, or hospital

(

)

______________________________________Physician’s Signature

Section C– Evaluation of Nursing Care Needed (check appropriate box only)

29.

Nutrition

30.

Bowel

31. Cardiopulmonary Status

32.

Mobility

33.

Behavioral Status

Regular

Age Dependent

Monitoring

Prosthesis

Agitated

Diabetic Shots

Incontinence

CPAP/Bi-PAP)

Splints

Cooperative

Formula-Special

Incontinent - Age > 3 years

CP Monitor

Unable to ambulate >

Alert

Tube feeding

Colostomy

Pulse Ox

18 months old

Developmental Delay

N/G-tube/G-tube

Continent

Vital signs > 2/days

Wheel chair

Mental Retardation

Slow Feeder

Other ________________

Therapy

Normal

Behavioral Problems

FTT or Premature

Oxygen

(please describe, if checked)

Hyperal

Home Vent

Suicidal

IV Use

Trach

Hostile

Medications/GT

Nebulizer Tx

Meds

Suctioning

Chest - Physical Tx

Room Air

34.

Integument System

35.

Urogenital

36.

Surgery

37.

Therapy/Visits

38.

Neurological Status

Burn Care

Dialysis in home

Level 1 (5 or > surgeries)

Day care Services

Deaf

Sterile Dressings

Ostomy

Level II (< 5 surgeries)

High Tech - 4 or more

Blind

Decubiti

Incontinent – Age > 3 years

None

times per week

Seizures

Bedridden

Catheterization

Low Tech – 3 or less times

Neurological Deficits

Eczema-severe

Continent

per week or MD visits > 4

Paralysis

Normal

per month

Normal

None

39.

Other Therapy Visits

40.

Remarks

Five days per week

Less than 5 days per week

41.

Pre-Admission Certification Number

42.

Date Signed

43. Print Name of MD or RN:_____________________________

Signature of MD or RN:_______________________________

DO NOT WRITE BELOW THIS LINE

44.

Continued Stay Review Date:

Admission Date ___________________ Approved for ______________Days or ___________Months

45.

Are nursing services, rehabilitative services or other health related services

46A. State Authority MH & MR Screening)

requested ordinarily provided in an institution?

Yes

Level I/II

Restricted Auth. Code

Date

46B. This is not a re-admission for OBRA purposes

47.

Hospitalization Precertification

Met

Not

Met

Restricted Auth. Code

Date

48.

Level of Care Recommended by Contractor

Hospital

Nursing Facility

IC/MR Facility

49.

Approval Period

50. Signature (Contractor)

51. Date

52. Attachments (Contractor)

________________

Yes

DMA-6A (10/2004)

Form DMA 6A – Fill Out and Use This PDF

Georgia DMA 6A Form PDF Details

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