Form Dma-5106 - Medicaid Referral printable pdf download

M E D I C A I D R E F E R R A L – P A G E 1

TO: _______________________________ FROM: ______________________________ DATE: _________

I. REQUEST FOR PACE INFORMATION (to be completed and signed by the Medicaid applicant/recipient)

I, ____________________________________,

have applied/reapplied for Medicaid. I authorize

(Print your name)

_____________________________________________________ to release the information requested on

(Print name of PACE provider)

this form to the ______________________________County Department of Social Services.

(Print name of county)

This authorization is valid for up to one year from the date signed. I understand that I may revoke this authorization at

any time by submitting a written request to the County Department of Social Services or PACE provider. I further

understand that any action taken on this authorization prior to the rescinded date is legal and binding.

_______________________________________ / _________________________

___________

Medicaid Applicant/Recipient or Representative’s Signature

Relationship to Recipient

Date

II. CONSUMER INFORMATION (to be completed by County DSS Staff)

PACE Services Requested

PACE Authorized

PACE Authorization Ends

Revision (Check one) Effective: _____________

Name: _________________________________ Medicaid ID #: __________________

Sex:

Female

Male

Address: ______________________________City _________________ County ______________ Zip _________

Phone: ________________________ Social Security #: __________________ Date of Birth: _________________

Responsible Person/Contact: _________________________ Phone: (Day) _____________ (Night) ____________

III. ELIGIBILITY INFORMATION (to be completed by County DSS Staff)

MEDICAID ELIGIBILITY STATUS

Caseworker Name: ___________________________ Phone: ______________ Email: ______________________

Status:

Not a current recipient

SSI Recipient

Medicare/Medicaid dual eligible

MAA/MAB/MAD/SA (circle one) Eligibility certification period ______________________________

Application Needed

Application Received on _______

Pending Application _______

(date)

(date applied)

Denial/Ineligible for PACE services due to: ________________________________________________________

CURRENT PACE AUTHORIZATION STATUS

PACE Approval Effective _______________ PML Amount $____________ Next Review: ________________

MEDICAID REVIEW COMPLETED

Approved – Next Review: _____________

Denied due to: ________________________________________

PML Change: Revised Amount $______________________ Effective: ________________________________

Comments: __________________________________________________________________________________

III. LEVEL OF CARE INFORMATION (to be completed by County DSS Staff)

Assessment Date: _______ NF Level of Care Approved

Yes

No (If Yes, please attach) Eff. Date: ________

Assessor’s Name: _______________________________________ Agency: ________________________________

dma-5106 (2/08)

Form Dma-5106 - Medicaid Referral

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