Medicaid Agency Waiver Page 2

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Start Date of PACE Services: ________________________________________________
Transitioning from one PACE Provider to another PACE Provider? Yes _____ No ____
Name of PACE Provider transitioning from: ____________________________________
End Date for above PACE Provider: __________________________________________
Name of new PACE Provider: _______________________________________________
Start Date for new PACE Provider: ___________________________________________
Entering Nursing Facility while enrolled in PACE Program? Yes _______ No _______
Date entering Nursing Facility: ______________________________________________
Request that Patient Liability be established:
Yes ________
No ___________
Anticipated date of discharge, if known: _______________________________________
Leaving Nursing Facility while enrolled in PACE Program? Yes ______ No ________
Date discharged from Nursing Facility: _______________________________________
Request that Patient Income be re-established: Yes _________
No ____________
*******************************
Signature and Title of Reviewer: ______________________________________________
Phone Number of Reviewer (______) ___________________________________________
Name and Fax Number for Award/Denial Notification ______________________________
Case Manager:_____________________________
Phone Number:__________________
District Office _________________________ ____________________________________
Phone Number of District Office (______) _______________________________________
Date Application Mailed to District Office _______________________________________
NOTE: LTC ADMISSION NOTIFICATION FORM SHOULD NOT BE
TRANSMITTED UNTIL FINANCIAL ELIGIBILITY IS ESTABLISHED.
*If this is an adoption subsidy recipient, a disability determination is required. Please route packet directly
to AMA Medical and Quality Review Services Unit. All other disability determinations should be sent to
the appropriate District Office.
Form 376
Alabama Medicaid Agency
 
Revised Date 12/01/2011

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Parent category: Medical
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