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  • Attachment - Form 216 - Scdhhs.gov - Scdhhs

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AMBULANCE AUTHORIZATION FORM FOR MEDICAID Beneficiary s Name Medicaid I.D. Number: I certify that it is medically necessary for this patient to be transported by ambulance. Transportation by any other.

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Adults: Only medically necessary exams are covered for adults. Retroactive services and routine eye exams are not covered. Children: One eye exam and glasses are covered for children. Copayments A copayment is a fixed amount you pay for a covered health care service, usually paid at the time you receive the service.

Coverage for Newborn Circumcisions Routine male circumcision is already a covered benefit for Healthy Connections Medicaid members who are enrolled in a managed care organization (MCO).

Parent/Caretaker Relatives (formally LIF) Family SizeMonthly Income (Eff. 03/01/2023)1753.3021,018.8631,284.4341,550.005 more rows

Verifying Eligibility for Enrolled Members Providers can access information online to help determine if an individual is enrolled in Medicaid through the South Carolina Medicaid Web Portal, commonly known as the “web tool.” To access the web tool, please visit https://portal.scmedicaid.com/login .

Healthy Connections, South Carolina's Medicaid program, does not pay for room and board at assisted living facilities but will pay for eligible medical expenses as well as personal care services and transportation to and from appointments. The state has a monthly income cap of $1,012 for those aged 65 and older.

You can also contact your Medicaid eligibility worker or call the South Carolina Healthy Connections Resource Center toll-free at 1-888-549-0820.

Groups & Programs Low Income Families (LIF) Qualified Disabled & Working Individuals (QDWI) Specified Low Income Medicare Beneficiaries (SLMB) Medically Indigent Assistance Program (MIAP) Optional State Supplementation Program(OSS) Working Disabled Program(WD)

Coverage includes: One routine vision exam every year. For members 21 and over: Glasses every two years, if needed. For members under 21: Glasses once per year, if needed.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232