If you're unfamiliar with DMA 6, it's time to learn more about this valuable legal tool. Below, you will find all the necessary details about the form.
Question | Answer |
---|---|
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 |
|
|
|
|
|
|
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_____________________ |
|
|
|
|
|
|
|
|
|
|
|
5. |
Primary Care Physician |
|
|
|
|
|||
|
|
|
|
|
|
|
|
|||
|
___________________________________________ |
|
|
|
|
|
|
|
|
|
|
|
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 |
|
|
|
1) |
Permanent |
|
|
|
|
|
|
|
communicable diseases? |
||||||||||||||||
|
|
Change Level of Care |
|
|
|
Private Pay |
|
Lives at home |
|
|
|
2) |
Temporary _______ estimated |
|
|
Yes |
|
No |
|||||||||||||||||||||||
|
|
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 |
|
|
|
|
|
|
|
|
|
|
|
|
Splints |
|
|
|
|
Cooperative |
|
|
||||||||||||||
|
|
|
|
|
Incontinent - Age > 3 years |
|
CP Monitor |
|
|
|
|
|
|
Unable to ambulate > |
|
Alert |
|
|
|
||||||||||||||||||||||
|
|
Tube feeding |
|
|
|
|
Colostomy |
|
|
|
|
|
|
Pulse Ox |
|
|
|
|
|
|
18 months old |
|
|
|
|
Developmental Delay |
|||||||||||||||
|
|
|
|
|
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 |
|||||||||||||||||
|
|
|
|
|
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. |
|
|
|
|
|
|
|
|
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 |
No |
|
|
|
Level I/II |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Restricted Auth. Code |
|
|
Date |
|
|
|
|||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
46B. This is not a |
|
|
|
|
|
|
|
|||||||||||
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 |
No |
|
|
|
|
|
|
|
|||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|