Get 2565 Facility Admission Notice
Tential beneficiary). It must be completed for potentially eligible Medicaid beneficiaries of all ages. The facility must retain THE ORIGINAL of the Facility Admission Notice in the beneficiary's file. A copy MUST be sent to the Local DHS Office. A copy of the MSA-2565-C will be returned to the facility, noting the eligibility status and patient pay amount of the resident. Authority: Completion: Penalty: P.A. 280 of 1939 and Federal 42 CFR of 435 Title XIX of the Social Security Ac.
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