Page 29

State of Maryland Medical Assistance Manual Revised April 2014

voids MMIS screen 4 (LTC) or screen 8 (waivers) to prevent payment to the LTCF, or for waiver services. The individual remains eligible for Medicaid services as indicated on MMIS screen 1.

8. DES/LTC 814- Trust/Document Review Request

This form is used to request a review of a trust or other document from the Division of Eligibility Services.

9. DES 1000 -Certification of Institutionalization & HealthChoice Disenrollment or Notification of Discharge from Long-Term Care (SAMPLE)

This form is used to disenroll a recipient from HealthChoice when they are in a long-term care facility (LTCF) for more than 30 days. The form is completed by the LTCF and the Administrative Services Organization. The original is sent to the Medical Assistance CM at the LDSS.

10. DES 2000 (LTC)- Physician’s Statement of Incapacitation

The CM uses this form when it its necessary for customer’s physician to verify that an applicant/recipient is not capable of participating in the application process. When this occurs a representative is needed to complete and sign the application and otherwise act in the customer’s behalf in the application process.

11. DES 2001 (LTC)- Request for Life Insurance Information

This form is used to obtain information from a specific life insurance company. The CM completes part one of the form. The second section is completed and signed by the representative, when the applicant/recipient is unable to sign the form, agreeing to provide information to the LDSS.

12. DES 2002 (LTC) -Consent to Release Information to LDSS

Form signed by the applicant/recipient/representative authorizing release of

information to the LDSS.

13. DES 2003 (LTC) -Income and Shelter Expense Reporting Form for Community Spouse

This form is used by the community spouse stating the amount of income he/she receives and the amount of his/her shelter expenses, for use in determining the spousal allowance.

14. DES 2004 (LTC) -Representative’s Statement

Form with two optional sections: • In the first section the applicant/recipient indicates who is to act as the representative. It is signed, by both the applicant/recipient and the representative, agreeing to provide information to the LDSS. • The second section is completed and signed by the representative, when the applicant/recipient is unable to sign the form, agreeing to provide information to the LDSS.