Forma Ma 34 Form PDF Details

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QuestionAnswer
Form NameForma Ma 34 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namescarta ma 10 reforma, ma 10 reforma online, certificación de medicaid ma 10, certificacion de reforma

Form Preview Example

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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How to fill out imprimir ma 10 reforma part 1

2. Once the last section is finished, you should add the required particulars in Certifico que quien es mi paciente, Certifico que los medicamentos, tiene una condición de, Permanente Indefinida, diagnóstico, y por tal razón utilizará los, Medicamentos y dosis, Uso Temporero, Uso continuo, Nombre del Médico en letra de, Firma del Médico, Fecha, columna a la izquierda tienen los, Precio Mensual, and Nombre del Farmacéutico Nombre de so that you can move forward to the next stage.

imprimir ma 10 reforma conclusion process clarified (part 2)

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