The LDS Church has updated its financial policy to require that all payments and donations over $1,000 must be reported on Form Ldss 3955. This new policy is designed to help the Church prevent fraud and ensure transparency in its finances. The form must be filled out by anyone making a payment or donation of this size, regardless of whether they are affiliated with the Church or not. Anyone who fails to comply with this policy may face disciplinary action.
| Question | Answer |
|---|---|
| Form Name | Form Ldss 3955 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | emergency certificate for medical claim esic, emergency certificate from hospital, medical emergency certificate, emergency certificate for medical reimbursement |
Rev. 02/07
CERTIFICATION OF TREATMENT OF EMERGENCY
MEDICAL CONDITION
NYS Department of Health Medical Assistance Program
PATIENT'S NAME (LAST) |
(FIRST) |
(MI) |
DATE OF BIRTH
ADDRESS: (STREET)
CITY
STATE
ZIP CODE
DIAGNOSIS:____________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
TREATMENT:___________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Date(s) of Treatment/Hospital Stay
(1). From_______________ To ________________ |
(3). From_______________ To ________________ |
(2). From_______________ To ________________ |
(4). From_______________ To ________________ |
Medicaid coverage may be available to the above named individual for care and services (exclusive of care and services related to an organ transplant procedure) that were necessary for the treatment of an "emergency medical condition." Under federal law [42 USC 1396b(v)(3), SSA 1903(v)(3) and 42 CFR 440.255] the term "emergency medical condition" means a medical condition (including emergency labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:
(A)Placing the patient's health in serious jeopardy;
(B)Serious impairment to bodily functions; or
(C)Serious dysfunction of any bodily organ or part.
This definition must be met at the time medical service is provided, or it will not be considered to be an emergency medical condition. Not all services that are medically necessary meet the Federal definition of emergency medical condition.
PHYSICIAN’S CERTIFICATION: in signing below, I certify that the care and services provided to the above named individual on the dates specified were for the purpose of treating an emergency medical condition as defined above.
The condition for which treatment was provided to the above named individual on the dates specified (please check box):
Meets the definition of emergency medical condition described above.
Does not meet the definition of emergency medical condition described above.
SIGNATURE OF ATTENDING PHYSICIAN/LICENSE NUMBER |
PRINT FULL NAME |
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PROVIDER/FACILITY NAME |
PROVIDER FACILITY MMIS ID NO. |
DATE |
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ADDRESS: (STREET) |
CITY |
STATE |
ZIP CODE |
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Attention
LDSS Worker
Please be sure that applicant/recipient signs the authorization on the
reverse side of this form (in the language of his/ her choice).
Page 2 of 2
Rev.02/07
AUTHORIZATION TO RELEASE MEDICAL
INFORMATION
NYS Department of Health Medical Assistance Program
I understand that the Local Department of Social Services must obtain information regarding emergency medical treatment rendered to me in order to determine my eligibility for medical assistance. I give permission to the local Department of Social Services to request such information and to the physician or facility to provide such information as requested by the local Department of Social Services for this purpose.
Signature of Applicant/Recipient: ____________________________________________ Date: _____________________
AUTORIZACIÓN DE REVELACIÓN DE DATOS
MÉDICOS
Tengo entendido que el departamento local de servicios sociales debe obtener los datos pertinentes al tratamiento médico de emergencia que se me suministró, con motivo de establecer mi habilitación para recibir asistencia médica. Yo doy permiso al departamento local de servicios sociales para que solicite dichos datos, como también al médico o instalación, a que revele dicha información para tal propósito tal como lo solicita el departamento local de servicios sociales.
Firma del solicitante/ beneficiario: _______________________________Fecha: _____________________