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State of Maryland Medical Assistance Manual Revised April 2014

LONG – TERM CARE PATIENT ACTIVITY REPORT

Community MA Waiver TO: LDSS

____________________________________

Address

____________________________________

____________________________________

FROM: Name of Facility ____________________________________

Address ____________________________________

____________________________________

MMIS Provider ID: ____________________________ CARES Vendor ID: ___________________

Contact Name:

Telephone

Provider Type Nursing Facility Chronic/Special Hospital Medical Day Center Other

___________________________________________________________________________________________________________________________ _

PATIENT INFORMATION Patient Name: ___________________________________ Sex:  M  F Date of Birth: _________________________________________ Medicare Claim No: __________________________________________ MD Medicaid No:

Patient Representative: __________________________________ Phone:

_________

Address: ______________________________________________________

_____________________________________________________

Number and Street

City/State/Zip Code _____________________________________________________________________________________________________________________ ACTION REQUESTED- COMPLETE EITHER SECTION A OR B AS APPROPRIATE, PRINT, SIGN AND DATE

A. Begin Payment

Admission Date

Private Pay Rate

Check all that apply (both beginning and ending pay dates must be completed when requested) NOTE: Actions marked with “*” require Utilization Control Agent/DHMH certification

1. *Full MA coverage

Begin pay date

For MDC only Initial Continued

2. Medicare A co- payment

Begin pay date

End pay date

3. Bed reservations for Medicare full coverage period Begin date

End pay date

4. *Revocation of Hospice Care and return to NF Care Effective date

B. Cancel Payment

1. Date of Discharge:

Discharged to: Another Facility Community Hospice

2. Death- Date of Death:

Administrator/Designee Signature

Date

Print Name of Administrator/Designee

Title

______________________________________________________________________________________________________________

Level of Care Certification (For UCA/DHMH USE ONLY)

The above named patient is certified for the following level of care (check one): Chronic/ Special Hospital Nursing Facility

Effective Dates

through

________________________________

Utilization Control Agent/ DHMH Authorized Signature M / D / YYYY

For Agency Use Only Date Received Control No. Due Date Completed DHMH 257 (Revised 07/13)