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State of Maryland Medical Assistance Manual Revised April 2014

Client Name_____________________________________

Maryland Medical Assistance Medical Eligibility Review Form #3871B Part A – Service Requested

Part B- Demographics

DHMH Form 3871B Rev 10/11 (1 of 4)

1. Requested Eligibility Date: _________________ 2. Admission Date:_________________ 3.Facility MA Provider #:______________________

4. Check Service Type Below:

Nursing Facility Medical Adult Day Care Wavier for Older Adults

Living at Home Waiver PACE

Model Waiver vent only dependent (all other MW use 3871)

Chronic Hospital vent dependent only (all other CH use 3871) 5. Check Type of Request

Initial Conversion to MA (NF)

Medicare ended (NF) MCO disenrollment (NF)

Readmission-bed Transfer new provider

Updated expired LOC Corrected Date

Reservation exp. (NF) (NF)

Significant change from Recertification

Advisory (please include payment)

Previously denied request (Waivers/PACE only)

1. Client Name: Last: _____________________ First: ______________________ MI_________ Sex: M F

SS#: _______ - _____ - _________ MA#: _______________________ DOB: _____________

2. Current Address (check one): Facility Home

Address 1 ___________________________________________________________

Address 2 ___________________________________________________________

City __________________________ State _______ Zip:

Phone

3. Next of Kin/Representative:

Last Name _____________________ First Name: ____________________________ MI

Address 1 ___________________________________________________________

Address 2 ___________________________________________________________

City __________________________ State _______ Zip _________________ Phone _________________________________

4. Attending Physician:

Last Name: _____________________ First Name _________________________ MI ____

Address 1 ___________________________________________________________

Address 2 ___________________________________________________________

City __________________________ State _______ Zip ______________ Phone __________________________________