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State of Maryland Medical Assistance Manual Revised April 2014

Attachment A PLEASE CHECK REQUESTED ACTION: [ ] CERTIFICATION OF INSTITUTIONALIZATION & HEALTHCHOICE DISENROLLMENT [ ] NOTIFICATION OF DISCHARGE FROM LONG-TERM CARE

TO: DHR/LDSS CM TO: DHMH HealthChoice District Office: ___________________________ Enrollment Section, Room L-9 Address: _______________________________ 201 W. Preston Street _______________________________ Baltimore, Maryland 21201

Part I. Recipient Identification Last Name __________________________ First __________________ M.I. ___ D.O.B. ____________

M.A. Number ______________________________ Social Security Number ______ - ______ - _______

Date of Admission to the Facility _______________________

Part II. Facility Identification Name _______________________________ CARES Vendor ID Number _______________________

Address ______________________________ MMIS Provider ID Number _______________________ ______________________________ Facility Phone Number ___________________________

______________________________ Facility Contact Person ___________________________

Part III. Recipient Under 21 Years Old To be completed after one full calendar month in the facility.

This certifies that this individual has been admitted to the above facility. The first full month of institutionalization began on ___________ / 1 / ___________ .

Part IV. Recipient Aged 21 Through 64 To be completed after the 30th consecutive day in the institution or after the 60th cumulative day during a calendar year in an institution.

This certifies that this individual has been institutionalized in the above facility

[ ] For 30 consecutive days, effective _________________________________________________

[ ] For 60 days during the calendar year, effective _______________________________________

Part V. Recipient 65 Years Old or Older To be completed after the 30th consecutive day in the facility.

This certifies that this individual was admitted to the above facility on ____________________________

and is considered institutionalized on that date.

Part VI. Discharge Information For Recipients Under 21 & Over 65 Years of Age To be completed upon discharge from the facility. This certifies that this individual was discharged from the above facility on ___________ to [ ] Home _______________________________________________________________________ [ ] LTCF _______________________________________________________________________ [ ] Other ________________________________________________________________________

Facility Certification: Signature ______________________ Date ___________ Phone ___________ Administrative Services Organization Authorization:

Signature _______________________

Date ___________ Phone ___________

DES 1000 Revised 01/09 White – LDSS/DEWS Yellow- DHMH Pink- IMD Blue-