Page 30

COMAR 10.09.24.05

529

State of Maryland Medical Assistance Manual Revised July 2012

Attachment A- DES 401 EMS Undocumented or Unqualified Aliens

EMERGENCY SERVICES TO UNDOCUMENTED OR UNQUALIFIED ALIENS

Date: _____________ To: Delmarva Foundation Attn: MDMA Acute 6940 Columbia Gateway Drive, Suite 420 Columbia, MD 21046-2788 1-888-513-1995 (fax number)

From: Local Department Name: _______________________

_ Local Department Address:

Telephone #: ___________________________________

_ SUBJECT: Determination of Emergency Services- Aliens Customer Name:

Customer Date of Birth:

Head of Household Name (if not the customer:

Case Number:

Date of MA Application:

Facility Name:

The above named applicant has submitted a Medical Assistance application for coverage of emergency services received from

to

.

(date) (date)

Federal category for which the applicant is eligible, but for his/her alien status:

FAC MCHP Aged Disabled/Blind

A copy of the following must be attached:

Discharged summary with admission and discharge dates

ER admission

Documentation showing the emergency nature of the medical services

I have checked and agree that the technical and financial information for the applicant has been reviewed and meets the MA requirements except for citizenship

Case Manager Signature: ____________________________________________

(Please sign your name)

Note: no bills or other extraneous information should be submitted

DES 401 (updated 11/11)