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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services D-540.11 Medical Assistance Manual CHANGES 16 Jan 01 MTL 01/16 FORMS USED FOR CONVERSION D-540.11 Forms Used for Conversion 2179 – Interface Consent: Request when spouse did not sign the application. Needed to access interfaces for verifying spouse’s income.

2734 – Home and Community Based Waiver Eligibility Status Form: Must be filed in permanent section to verify recipient meets level of care requirements.

3004 – Disability/Incapacity Determination Request: Must be filed in permanent section to verify recipient meets disability criteria. Applicable to institutional less than 30 days, home and community-based waivers, emergency medical, Katie Beckett, and prior medical.