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State of Maryland Medical Assistance Manual Revised July 2012

DHMH 4242 (LTC) Attachment H Home Exclusion

MARYLAND MEDICAL ASSISTANCE PROGRAM HOME EXCLUSION – STATEMENT OF INTENT Date: ____________________________________ PART I. INSTITUTIONALIZED PERSON‟S IDENTIFICATION (To be completed by the Local Department of Social Services)

1. __________________________________________ ____________________________________

Name

Client ID 2. __________________________________________ ____________________________________

Name of Facility

Telephone Number

Address 3. ___________________________________________ ____________________________________ Representative‟s Name

Telephone Number

Address

4.

Case Manager Department of Social Services Telephone Number