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Medical Eligibility Review Form

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Maryland Medical Assistance

Medical Eligibility Review Form #3871B

Part A – Service Requested

1. Requested Eligibility Date:

2. Admission Date

3. Facility MA Provider #:

_________________________

_____________________

____________________________

4. Check Service Type Below:

Nursing Facility

Medical Day Care Waiver

Waiver for Older Adults

Model Waiver vent only dependent

Living at Home Waiver

PACE

(all other MW use 3871)

Chronic Hospital vent dependent only (all other CH use 3871)

5. Check Type of Request

MCO disenrollment

Initial

Conversion to MA (NF)

Medicare ended (NF)

(NF)

Readmission – bed

Transfer new provider

Update expired LOC

Corrected Date

reservation exp. (NF)

(NF)

Significant change from

Recertification

Advisory (please include payment)

previously denied request

(Waivers/PACE only)

Part B – Demographics

1. Client Name: Last ________________________First ______________________ MI _____ Sex: M

SS# ______- ____- _______

MA # __________________________ DOB __________

2. Current Address (check one):

Facility

Home

Address 1 ___________________________________________________________________________

Address 2 ___________________________________________________________________________

City __________________________ State _______ ZIP _____________ Phone ___________________

If placed in facility, name of facility ______________________________________________________

If in acute hospital, name of hospital_______________________________________________________

3. Next of Kin/ Representative

Last name _________________________ First Name _______________________ MI _____

Address 1 ____________________________________________________________________________

Address 2 ___________________________________________________________________________

City ___________________________ State _________ ZIP ___________ Phone __________________

4. Attending Physician

Last name _________________________ First Name _______________________ MI _____

Address 1 ___________________________________________________________________________

Address 2 ___________________________________________________________________________

City ____________________________ State _________ ZIP ___________ Phone _________________

DHMH Form #3871B

Page 1 of 4

Rev 10/11

Medical Eligibility Review Form

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