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State of Maryland Medical Assistance Manual Revised July 2012 Attachment E Physician Report

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