Georgia DMA-6A Form PDF Details

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.

QuestionAnswer
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

Form Preview Example

 

 

 

 

 

 

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

 

 

 

 

 

 

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

No

 

 

 

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

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DMA-6A (10/2004)