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State of Maryland Medical Assistance Manual Revised April 2014
To: Division of Recipient Eligibility Programs 201 West Preston Street Room SS-7C Baltimore, Maryland 21201
From:
Department of Social Services
Local Department
_________________________________________________________________________________________________
Name of Recipient__________________________________________________________________________________
First M.I. Last
M.A. I.D. _________________________________________________________________________________________
Name of Facility ___________________________________________________________________________________
MMIS Provider I.D. ________________________________________________________________________________
Requested Begin Pay Date ___________________________________________________________________________
Date of Discharge __________________________________________________________________________________
Recipient Certified under Spend-down
Excess income remaining on first day of eligibility: $____________________________________________________
Worker Signature:
Date
Telephone No.
DES 501 (Revised 12/08) White-DREP Yellow- Long Term Care Facility Pink- Case Record