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COMAR 10.09.24.12

1220 State of Maryland Medical Assistance Manual Revised July 2012 To: Division of Recipient Eligibility Programs 201 West Preston Street Room SS- 7C Baltimore, Maryland 21201

From: _____________________________ Department of Social Services

(Local Department)

Name of Recipient __________________________________________

First

M.I.

Last M.A. I.D. _____________________________________

Name of Facility _______________________________

MMIS Provider I.D. _____________________________

Requested Begin Pay Date ________________________

Date of Discharge _______________________________

Recipient Certified under Spend-down. Excess income remaining of first day of eligibility: $__________________________

Worker Signature: _______________________________ Date: ___________________

Telephone No. ______________________________

DES 501 Revised 12/08 White-DREP Yellow-Long Term Care Facility Pink-Case Record