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1110 State of Maryland Medical Assistance Manual Revised July 2012 Attachment E- Recipient Eligibility Display Screen Recipient Eligibility Display Screen DATE

RECIPIENT ELIGIBILITY DISPLAY SCREEN 1 Reissue:

Last Trans: 000000 User: 00 RECIP-ID: 400000

HOE/CASE-NUM: 40000

BATCH-UP: 00000000 ORIG-ID: 4000000

CARES-TRN: 4000000

PREV-UP: 0000000 CURR-ID: 400000

SSN: 0000000

MEDICARE-NUM: 00000 NAME: XXXX

R_________ M A/P N ELIG: 000

(PF1) HOH: R M P ______ APPL-DT: 00000

HMO: XXXX

(PF2) ADDR: APT______ INSR: T8 TPL:

MEDICARE:

(PF3) ADDR: 00________RD DEC-DT: 00000

LTC:

(PF4) CITY: XXXXXX

BIRTH: 00 00 0000 WAIVER:

(PF5) STATE: XX ZIP: XXXX RACE: X SEX: X MANAG-CARE:

(PF6) PHONE: 00000000000 HOSP-NUM: XXX NEW –IDS: XXX

(PF7) RES-CNTY: XXX COUNTY DT-OF-ENTRY: XXX SPECIAL PROGRAM (PF8) PREV-CNTY: XX DIST-OFF: XXX UNIT: XX DEATE: XX MCO: X (PF9) INCOME: 000 ASSETS: 000 ORIGIN: X CARES-DT: 00000 SCREEN-DT: 000 EPSDT: X RETURN-CD: VCN: X ISSUE-DT: 000000 ______________________________ELIGIBILTY SPANS______________________________ NO BEGIN END COV TYP CAT SCP SPLT-AMT CIT SRC CN-RSN EVS-DT LST-TRAN 01 0000 00000 000 0 0.00 0 0 00000 00000 02 0000 00000 000 0 0.00 0 0 00000 00000 03 04 05