MA-34 Form PDF Details

In the realm of healthcare administration within Puerto Rico, the Forma MA-34 emerges as a critical document for individuals enrolled or seeking enrollment in the Medicaid program. This form serves as a means for applicants to certify their fixed expenses on medications, a process that underscores the synergy between patients, healthcare providers, and pharmacists in the pursuit of accurate and equitable healthcare support. Through the form, the head of a family unit declares the ongoing medication expenses, a declaration that necessitates validation by both the attending physician and the pharmacist. Physicians detail the patient’s condition and the required medications, whether for ongoing or temporary use, while pharmacists confirm the monthly costs associated with these prescriptions. Beyond its functional role in healthcare cost management, the form also embodies a legal document; applicants and their healthcare partners are reminded of the serious implications of providing false information, reinforcing the document's importance in maintaining the integrity of Puerto Rico's Medicaid system. Signatures from patients (or their legal representatives), the prescribing physician, and the pharmacist are all requisite, completing a chain of accountability that ensures the information provided is both accurate and verifiable.

QuestionAnswer
Form NameMA-34 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesma 10 reforma online, certificacion de reforma ma 10, cómo conseguir la ma 10, ma 10 reforma certificación online

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MA-34

ESTADO LIBRE ASOCIADO DE PUERTO RICO

Rev. 05/09

DEPARTAMENTO DE SALUD

O.N.

PROGRAMA MEDICAID

 

Número Unidad Familiar______________________________________

Nombre Jefe Unidad Familiar______________________________________

CERTIFICACION DE GASTOS FIJOS POR MEDICAMENTOS

AUTORIZACION DEL SOLICITANTE O RESOLICITANTE O PERSONA ENCARGADA

Por la presente autorizo al Programa Medicaid del Departamento de Salud a que

esta información sea comprobada con la fuente correspondiente.

_______________________________

____________________________________

(Testigo de la marca)

(Firma del Paciente)

 

_____________________________________________

 

(Fecha)

CERTIFICACION DEL MEDICO

Certifico que ______________________________________ quien es mi paciente

tiene una condición de _____________________________________________________.

(diagnóstico)

Permanente Indefinida

y por tal razón utilizará los siguientes medicamentos:

Medicamentos y dosis

Uso Temporero

Uso continuo

1.

2.

3.

4.

5.

Nombre del Médico en letra de molde

 

Núm. Lic. del Médico

 

 

 

Firma del Médico

 

Fecha

CERTIFICACION DEL FARMACEUTICO

Certifico que los medicamentos indicados por el médico en la columna a la izquierda tienen los siguientes costos:

Precio Mensual

1.

2.

3.

4.

5.

Nombre del Farmacéutico

 

 

Nombre de Farmacia

 

 

 

 

 

 

Firma del Farmacéutico

 

Lic. Farmacéutico

 

Fecha

Toda persona que ofrezca información falsa con conocimiento de que no es correcta con el propósito de que la persona se beneficie de servicios del Programa Medicaid, será acusado y procesado por violación a las leyes penales de Puerto Rico.

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