Page 84
State of Maryland Medical Assistance Manual Revised April 2014
MARYLAND MEDICAL ASSISTANCE PROGRAM PHYSICIAN REPORT
Date:__________________ PART I. INSTITUTIONALIZED PERSON’S IDENTIFICATION (To be completed by the Local Department of Social Services)
1. _____________________________________ ______________________ Name CID#
2. _____________________________________ _______________________ Name of Facility Telephone Number
Address
3. ______________________________________ ________________________ Representative Name Telephone Number
Address
4. ________________________ __________________________ _________________________ Case Manager Department of Social Services Telephone Number
________________________________________________________________________________________________ Address
PART II. STATEMENT BY ATTENDING PHYSICIAN
1. The anticipated length of stay in a Long Term Care Facility for the above named patient is: (check the appropriate box)
Remainder of Life
* Six Months or Less
* More Than Six Months
* (give expected month and year of discharge_____________)
2. The medical reasons for this expectation are:
(use back for additional space)
3. This person’s ability to resume community (non-institutional) living requires the following support systems:
Medical Day Care Home Health Care
Personal Care
Other________________________
No support system(s) will be needed Specify I certify that I am the attending physician of the above name person and that the statements I have made concerning this person are based on my professional assessment of his/her medical condition and are supported by the person’s medical record.
_____________________
_______________________
_____________________ Signature of Physician Printed Name of Physician Date
_____________________________________
Address
Notice to Medicaid Applicants
You are providing personal information (Name, Address, Date of Birth, Income History, Employment History, etc.) in this application for Medicaid benefits.
The purpose of requesting this personal information is to determine your eligibility for Medicaid. If you do not provide this personal information, the Medicaid Program may deny your application for benefits. You have a right to inspect, amend, or correct this personal information. The Medicaid Program will not permit inspection of your personal information, or make it available to others, except as permitted by federal and state law.
DHMH 4245 Revised 7/13