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State of Maryland Medical Assistance Manual Revised April 2014

MARYLAND MEDICAL ASSISTANCE PROGRAM

PHYSICIAN’S STATEMENT OF INCAPCITATION

Date

This is to certify that

has been under my professional care from

to

For the treatment of

.

I certify that he/she is (check one):

capable incapable of participating in the application process, and signing the application.

Signature of Physician

Print Name of Physician

Address

Phone Number

DES 2000 (LTC)-Revised 11/03