Get Dma 5170

Filling out the Dma 5170, the request for claims override form, is an essential step for individuals seeking assistance with their Medicaid claims. This guide will walk you through each section of the form to ensure that your request is complete and accurate.

Follow the steps to complete the Dma 5170 form efficiently.

1. Click 'Get Form' button to obtain the Dma 5170 and open it in your editor.
2. Complete the 'From' section with your telephone number and the name of your county department of social services.
3. In the 'Date' field, enter the current date when you are filling out the form.
4. Provide the recipient's name and MID (Medicaid identification number) in the designated fields.
5. Fill in the 'Date of Application' and 'Date of Disposition' as applicable to your case.
6. Select the appropriate reason for your override request from the listed options, ensuring to complete any required supplementary information.
7. Input the onset of disability date if relevant to your selected reason for the override.
8. Indicate the 'Date notice of approval received by DSS' or any other related dates required depending on your chosen reason.
9. If applicable, provide dates related to the county or state hearing decision, application reopening due to discouragement, and any relevant administrative errors.
10. List the eligible dates in the EIS for which the override is needed in the designated area.
11. Specify the recipient of the override approval notice, along with the name and address of the responsible person, if different from the recipient.
12. Review all entered information for accuracy, making any necessary corrections.
13. Save the changes, download, print, or share the completed form as required.

Take the next step in managing your Medicaid claims by filling out the Dma 5170 online today.