Form Dma-5106 - Medicaid Referral (Page 2 of 2) in pdf

P AC E R E F E R R A L - - P A G E 2

TO: _______________________________ FROM: ______________________________ DATE: _________

I. REQUEST FOR MEDICAID INFORMATION

(to be completed and signed by the PACE applicant/recipient)

I, ____________________________________,

have applied/reapplied for Medicaid. I authorize

(Print your name)

_____________________________________________________ to release the information requested on

(Print name of PACE provider)

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understand that any action taken on this authorization prior to the rescinded date is legal and binding.

_______________________________________ / _________________________

___________

PACE Applicant/Recipient or Representative’s Signature

Relationship to Recipient

Date

II. CONSUMER INFORMATION (to be completed by PACE Staff)

New Enrollment

Disenrollment

Withdrawal

Revision

Effective: __________

(Check one)

Name: _________________________________ Medicaid ID #: __________________

Sex:

Female

Male

Address: ______________________________City _________________ County ______________ Zip _________

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

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

III. PACE ENROLLMENT INFORMATION (to be completed by PACE Staff)

Referred to DSS to Apply for Medicaid/PACE services

Mail-In Application Taken

Application Mailed on_____(date)

(Please attach)

COMPLETE FOR NEW PACE APPLICANTS:

Enrollment Approved

Enrollment Date: _____________________________________________

Enrollment Withdrawn by Applicant

Reason: _____________________________ Date: ______________

Enrollment Denied by PACE

Reason: _____________________________ Date: _________________

COMPLETE FOR CURRENT PACE PARTICIPANTS:

Temporary Nursing Facility Placement Date: _____ Facility: _____________ Est. Length of Stay: _______

Permanent Nursing Facility Placement Date: _____ Facility: _____________

DISENROLLMENT INFORMATION:

Voluntary Disenrollment

Effective Date: _______________ Reason: ______________________________

Involuntary Disenrollment

Effective Date: _________________ State Approved:

Yes

Death

Date of Death: _______________________

Comments: __________________________________________________________________________________

IV. LEVEL OF CARE INFORMATION (to be completed by PACE 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 Page 2

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