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State of Maryland Medical Assistance Manual Revised April 2014
Medical Care Transaction Form
TO: Department of Health & Mental Hygiene Re: Name: _________________________ Medical Care Operations Administration 201 West Preston Street, SS-18
M.A. No. _|__|_|_|_|_|__|_|_ Baltimore, Maryland 21201
Nursing Home Section Chronic Care Section
FROM: _______________________________________
Nursing Home/Chronic Facility
_______________________________________
Street Address
_______________________________________
City State Zip Code
Cancel Pay Effective ________ _______ _______
Mo. Day Yr. No longer NFS No longer Chronic Care
Begin Pay Effective ________ ________ _______
Mo. Day Yr.
* Admitted to Chronic Care * Admitted to NFS
_______________________________________ __________________ _______________
Signature of Facility Administrator MCOA Date Telephone Number
DHMH 259 (Revised 7/13) White – LDSS/DEWS Yellow- LTCF Pink- UCA
UCA USE ONLY Level of Care Eff . ___ ___ ___
Mo. Day Yr. Intermediate Skilled Chronic
Utilization Control Agent
Authorized Signature
Date