Se number RE: State Zip Social Security or health insurance benefit (HIB) number Date of birth Sex Race Patient is in a Title XVIII certified skilled bed Will patient remain in facility when skilled care days end? Yes No Unknown Section I. Admission. Patient was admitted to this facility on (date): location): SoonerCare (Medicaid) financial eligibility approved? SoonerCare (Medicaid) medical eligibility approved? from (previous Yes Yes No No When did patient transfer from skilled ca.
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How to fill out the 08ma083e Form online
The 08ma083e Form is essential for notifying the Oklahoma Department of Human Services regarding the admission or discharge of patients in nursing facilities, ICF/MR facilities, and hospices. This guide will assist you in accurately completing the form online with comprehensive steps to follow.
Follow the steps to fill out your form effectively.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- In the 'To' section, enter the address of the local OKDHS office to which you are submitting the form.
- In the 'From' section, provide the name, street address, city, state, and provider number of the facility or hospice sending the form.
- Under 'Re:', fill in the patient's name, former address, client identification number, SoonerCare case number (if applicable), Social Security or health insurance benefit number, date of birth, sex, and race. Indicate if the patient is in a Title XVIII certified skilled bed and whether they will remain after skilled care days end.
- For Section I (Admission), enter the admission date, immediate previous location, and check whether the patient is a new admission or returning from a hospital stay. Also, check if SoonerCare financial and medical eligibility is approved if known.
- Specify the type of admission by checking the appropriate box for NF admission, ICF/MR admission, or hospice admission, and ensure necessary documents are on file based on the type selected.
- If the patient returned from a hospital, record the hospital name and the name and address of their physician.
- In Section II (Discharge), enter the discharge date and check the appropriate box to indicate where the patient was discharged to, whether it was a hospital or if the patient has passed away, including the date of death.
- The form must be signed and dated by the operator or representing individual.
- Finally, ensure to save your changes, then download, print, or share the form as needed based on your requirements.
Complete your forms online today for efficient processing of your patient notifications.
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(2) The facility will notify the local county office by the OKDHS Form 08MA083E...
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