The 3871 Maryland Medicaid form is a crucial document used to assess an individual's eligibility for medical assistance services in Maryland. This form collects essential information about the patient's demographics, medical history, and the level of care required. Proper completion of this form is vital for ensuring that individuals receive the necessary support and services they need.
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The 3871 Maryland Medicaid form is a crucial document for individuals seeking medical assistance through the Maryland Medical Assistance Program. This form plays a key role in determining a patient’s eligibility for various levels of care, including nursing facilities, medical day care, and rehabilitation hospitals. It consists of several parts, starting with patient demographics, where essential information such as the patient's name, date of birth, and social security number is collected. The form also requires details about the patient's current medical condition, including primary and secondary diagnoses, medications, and any ongoing treatments. Physicians must complete a plan of care to support the application, detailing the patient's needs and treatment history. Additionally, the form assesses functional and cognitive status, ensuring a comprehensive evaluation of the patient’s capabilities and requirements. Overall, the 3871 form is designed to gather detailed information to facilitate appropriate care and services for patients in need.
Maryland Crn - The form is available online for easier and more efficient completion.
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Maryland Intake Sheet - Arms-length transactions indicate no duress between unrelated parties.
Maryland Medical Assistance Program
Medical Eligibility Review Form PLEASE PRINT OR TYPE
Level of Care/Services Requested (application for rehab
Application Date: ________________________
hospitals must be accompanied by a plan of care from admitting
Financial Eligibility Date:__________________
hospital) (Please check)
Social Security #:_________________________
Medical Assistance #:_____________________
Chronic Hospital* Model Waiver*
(If patient is on a ventilator, please use the DHMH 3871B with the Ventilator Questionnaire)
Part A: Patient Demographics
Patient’s Last Name: ____________________________________
Patient’s First Name: _______________________
Patients Date of Birth: __________ Sex: ____Adm. Date: ________
Permanent Address: ____________________________________
_____________________________________________________
Name of Last Provider (Hospital, Long Term Care Facility)
Present location of Patient: (if different from above)
Institution: ___________________________________
______________________________________________________
Admission Date: _______________________________
Discharge Date: _______________________________
Patient’s Representative Name: ____________________________
Relationship to Patient: _________________________
Representative Phone #: __________________________________
Representative Address: ________________________
Is language a barrier to communication ability? ___YES ___NO
____________________________________________
****************************************************************************************************************
Part B: Physician’s Plan of Care (Must be completed by physicians or designee)
Please fill out accurately and completely
Physicians Name: ____________________________ Telephone #: _________________ Address: ______________________
Primary Diagnoses which relate to need for level of care: _______________________________________________________
Secondary/Surgical Diagnoses currently requiring M.D. and/or Nursing intervention which relates to level of care:
__________________________________________________________________________________________ Date: ________
Other pertinent findings (ex. Signs and symptoms, complications, lab results, etc… ____________________________________
_______________________________________________________________________________________________________
_____________________________________________________________________________________________
Is patient free from infection TB? ____YES ____ NO Determined by: ___ Chest X-Ray ___PPD Date: ___________________
T __________ P __________ R ___________ B/P __________ HT __________ WT __________
Have any of the above vital signs undergone a significant change? ___YES ___NO If Yes explain: _____________________
Diet (Include supplements and tube feeding solution) ___________________________________________________________
DHMH 3871 rev. 4/95
Medical Review Form
Page 1 of 4
Patient’s Name: ______________________________
Medication which will be continued:
Medication
Dosage
Frequency
Route
If PRN, avg frequency
Treatment which will be continued: DescriptionFrequencyDuration if Temporary
____ Ventilator: ____________________________________________________________________________________
____ O2 (as well as sats and frequency): _________________________________________________________________
____ Monitor (apnea/bradycardia (A/B), other: ___________________________________________________________
____ Suctioning: ____________________________________________________________________________________
____ Trach Care: ____________________________________________________________________________________
____ IV Line/fluids (indicate central or peripheral): _________________________________________________________
____ Tube Feeding (specify type of tube): ________________________________________________________________
____ Colostomy/ileostomy care: _______________________________________________________________________
____ Catheter/continence device (specify type): __________________________________________________________
____ Frequent labs related to nutrition/needs (describe): ___________________________________________________
____ Decubitus (include size, location, stage, drainage, and signs of infection, also Tx regimen): _____________________
__________________________________________________________________________________________________
____ Other (specify): ________________________________________________________________________________
Have any medications or treatments recently been implemented, discontinued, and/or otherwise changed? Explain:
_______________________________________________________________________________________________
Impairments/devices (check all that apply) ___Speech ___Sight ___Hearing ___Other (specify) ______________________
___Devices/Adaptive Equipment ________________________________________________________________________
Active Therapy
Plan
Est. Duration
Goal
Physical Therapy
Occupational Therapy
Speech Therapy
Respiratory
Others
Page 2 of 4
Patient’s Name: 5674
Rehabilitation Potential: ______________________________________________________________________________
Discharge Plan: _____________________________________________________________________________________
*If requesting a level of care for rehab hospital, please answer the following questions:
1.Preexisting condition related to current physical, behavioral and mental functions and deficits: __________________
2.Reason for out-of-state placement (if applicable): ______________________________________________________
Is patient comatose? ___YES ___NO if yes skip parts C through E and go directly to part F.
PLEASE NOTE: For other adults applicants, complete parts C and D, skip E. For applicants under age 21, skip parts C and D, complete E.
*************************************************************************************************
Part C: Functional Status (Use one of the following codes)
(If assistive device (e.g., Wheelchair, Walker) used, note functional ability while using device)
0.
Little or no difficulty (completely independent
2.
Limited physical assistance by caregiver
or setup only is needed
3.
Extensive physical assistance by caregiver
1.
Supervision/Verbal cuing
4.
Total dependence on others
___ Locomotion (if using adaptive/assistive device,
___ Dressing
Specify type): _____________________________
___ Bathing
___ Transfer bed/chair
___ Eating
___ Reposition/Bed mobility
Appetite (Check one): ___ Good ___ Fair ___ Poor
Other functional limitations (describe) ______________________________________________________________________
Incontinence management (Circle applicable choices in each category) (Note status with toileting program and/or continence device, if applicable)
Bladder
Bowel
0
Complete control-or infrequent stress incontinence
1
Usually continent-accidents once a week or less
2
Occasionally incontinent- accidents 2+ weekly, but not daily
3
Frequently incontinent- accidents daily but some control present
4
Incontinent- Multiple daily accidents
*******************************************************************************************************
Part D: Cognitive/Behavioral Status
1. Memory/orientation
Y=Yes
N=No
2. Cognitive skills for daily life decision making and safety (Check one)
Yes
No
___
Can recall after 5 minutes
Independent decisions consistent and reasonable
Knows current season
Modified/some difficulty in new situations only
Knows own name
Moderately impaired/decisions requires cues/supervision
Can recall long past events
Severely impaired/rarely or never makes decisions
Knows present location
Knows family/caretaker
3. Communication
0- Always
1-Usually
2-Sometimes 3-Rarely
Ability to understand others
_____
____
Ability to make self understood
Ability to follow simple commands
Page 3 of 4
Patient’s Name ____________________________________
4. Behavior issues (enter one code from A and B in the appropriate column)
A. Frequency
B. Easily Altered
1= Occasionally
1= Yes
2=Often, but not daily
2= No
3= Daily
Description of Problem Behaviors
A
B
5.Most recent mini-mental score ___________________________________ Date: __________________________
Previous mini-mental score ______________________________________ Date: __________________________
Part E: Functional/Cognitive Status – Pediatric
Age Appropriate
Functioning Level
Adaptive Equipment
Cognition
Wheelchair
Social Emotional
Splints/Braces
Behavior
Side Lyer
Communications
Walker
Gross Motor Abilities
Adaptive Seating
Fine Motor Abilities
Communication Devices
Feeding
Other
Toileting
Self Care
Part F: Physician’s Certification for Level of Care
This patient is certified as in need of the following services (Check One):
Chronic Hospital
Model Waiver
Other information pertinent to need for Long Term Care: _________________________________________________________
Physician’s Signature: ___________________________________________________________ Date: _____________________
Other than physician completing form: ________________________________________________________________________
SignatureTitlePhoneDate
**********************************************************************************************************
This area is for Agent Determination Only. DO NOT write in this area.
Renewal
___ Medical Eligibility Established
MD Advisor ___
___Medical Eligibility Established
MD Advisor___
___ Medical Eligibility Denied
Effective Date: _____________________
Type of Service: _________________________________
Type of Service: __________________________________
Certificate Period: From: _____________ To: ___________
Agent Signature: _________________________________
Agent Signature: __________________________________
Date: ___________________________________________
Page 4 of 4
1. The 3871 form is only for nursing home admissions. Many believe this form is exclusively for nursing home applications. In reality, it covers various levels of care, including rehabilitation hospitals and medical day care.
2. All sections of the form must be completed by a physician. While a physician must fill out the plan of care section, other parts can be completed by designated staff or representatives, ensuring a smoother process.
3. The form is only relevant for elderly patients. The 3871 form applies to individuals of all ages. It can be used for children and adults seeking long-term care services.
4. Submitting the form guarantees approval for services. Filling out the form does not automatically ensure eligibility. The application will be reviewed, and approval is based on medical necessity and other factors.
5. Patients must be comatose to qualify for certain services. This is a misconception. Patients who are alert and able to participate in their care can still qualify for various levels of assistance.
6. The form is too complex to fill out without legal assistance. While the form requires detailed information, it is designed to be user-friendly. Most applicants can complete it with guidance from healthcare providers.
7. There is no need to update the form once submitted. Changes in a patient's condition or care needs may require updates to the form. Keeping it current is essential for accurate assessments.
8. Only the patient can provide information for the form. Family members or legal representatives can provide necessary details, especially if the patient is unable to do so. This helps ensure a complete and accurate application.
Filling out the Maryland Medicaid form, known as the 3871, can be a daunting task. Many people make common mistakes that can delay the process or even lead to denial of services. Understanding these pitfalls can help ensure a smoother application experience.
One frequent mistake is not providing complete patient demographics. This section requires accurate information, including the patient's full name, date of birth, and Social Security number. Omitting or misspelling any of this information can cause confusion and may lead to processing delays. Always double-check this section before submitting the form.
Another common error involves the physician's plan of care. This part must be filled out by a physician or their designee. Some applicants mistakenly try to complete this section themselves, which can result in incomplete or incorrect information. It’s crucial to have a qualified medical professional provide their input, as this section details the patient's medical needs and justifies the level of care being requested.
Many applicants also overlook the importance of the functional status section. This part assesses the patient's daily living skills and cognitive abilities. Failing to accurately describe the patient's capabilities can lead to an inappropriate level of care being assigned. It’s important to be honest and thorough when indicating how much assistance the patient requires in daily activities.
Lastly, applicants often forget to sign and date the form. This may seem minor, but an unsigned form will be considered incomplete. Ensure that all required signatures are present, including those from the physician and any representatives involved in the application process. A missing signature can halt the review process and delay necessary services.
By being aware of these common mistakes and taking the time to fill out the Maryland Medicaid form carefully, applicants can improve their chances of a successful application. Attention to detail is key in ensuring that the patient receives the appropriate level of care they need.
Ensure that all information is filled out accurately and completely. This includes patient demographics, physician's plan of care, and any necessary medical history.
Use clear and legible handwriting or type the information. This helps prevent misunderstandings and ensures that all details are easily readable.
Check the appropriate level of care or services requested. This could include options like rehab hospitals, medical day care, or chronic hospitals.
Provide a detailed physician's plan of care. This section must be completed by a physician or their designee and should include primary and secondary diagnoses.
Indicate any barriers to communication, such as language issues. This can help ensure that the patient receives appropriate support during the application process.
Be aware of the importance of the discharge plan. This outlines the future care needs and helps in planning for the patient’s ongoing support.
Review the form for completeness before submission. Missing information can delay the processing of the application and affect the patient’s access to necessary services.
The Maryland Medicaid Form 3871 is a key document used in the application process for medical assistance. Alongside this form, several other documents are often required to ensure a comprehensive evaluation of eligibility and care needs. Below is a list of these forms and documents, each serving a specific purpose in the Medicaid application process.
Gathering these documents can streamline the application process and ensure that all necessary information is available for review. It is advisable to keep copies of all submitted materials for personal records.
The Maryland Medicaid 3871 form is similar to the Medicare Application for Enrollment (CMS-10106). Both documents serve as applications for medical assistance, requiring detailed personal and financial information. They collect demographic data, including the applicant's name, date of birth, and social security number. Additionally, both forms require information about current medical conditions and treatment plans, ensuring that the applicant's needs align with the services provided under the respective programs.
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Another document that parallels the Maryland Medicaid 3871 form is the Long-Term Care Application for Medicaid. This form also gathers extensive information about the applicant's health status and care needs. Like the 3871, it includes sections for detailing medical diagnoses and treatment plans. Both forms aim to assess eligibility for long-term care services, making it essential for applicants to provide accurate and comprehensive information regarding their health and financial situations.
The Uniform Assessment Instrument (UAI) is another document similar to the Maryland Medicaid 3871 form. The UAI is used to evaluate an individual's functional abilities and care needs. Both forms assess the applicant’s physical and cognitive status, including their ability to perform daily activities. The UAI also gathers information about the individual’s medical history, which is crucial for determining the appropriate level of care, much like the 3871 form does.
Lastly, the Home and Community-Based Services (HCBS) Waiver Application resembles the Maryland Medicaid 3871 form in its purpose and structure. Both documents are designed to evaluate eligibility for specific health services and supports. They require information on the applicant's medical conditions and care requirements. The HCBS application focuses on community-based services, while the 3871 form is used for various medical assistance services, but both ultimately aim to ensure that individuals receive the appropriate level of care based on their unique needs.