Get Dma-5106pdf Medicaid Pace Program Referral - Info Dhhs State Nc

Filling out the Dma-5106pdf Medicaid PACE Program Referral form online can be straightforward and efficient. This guide provides detailed instructions to help users complete the form accurately and understand each section's purpose.

Follow the steps to complete the Dma-5106pdf form online.

1. Click ‘Get Form’ button to access the form and open it in your editor.
2. In the first section labeled 'Request for PACE Information', enter your name in the designated field to indicate the Medicaid applicant or recipient. Below that, specify the name of the PACE provider you are authorizing to release your information to the county department. Next, provide the name of the county department where the information will be sent.
3. The next section, 'Consumer Information', should be populated by County DSS staff. If you are filling this out online, ensure that it is marked for completion by the appropriate staff member. This includes details such as requested PACE services, authorization status, and personal information like sex, address, and contact numbers.
4. In the 'Eligibility Information' section, County DSS staff will fill in the Medicaid eligibility status. Users should ensure they provide all necessary information that will allow for eligibility verification.
5. For 'Level of Care Information', ensure that the assessment date and level of care approval status are noted correctly. This section will require input from the assessing staff.
6. Continue to the second page, starting with another 'Request for Medicaid Information', where the applicant must again provide their name and the name of their PACE provider. The county name must also be indicated.
7. In the 'PACE Enrollment Information' segment, staff will fill out the status of the application. If new, confirm enrollment approval and the approved enrollment date.
8. Finally, after ensuring all sections are complete and correct, save your changes, and download or print the form to keep a record or for submission.

Complete the Dma-5106pdf online and ensure timely processing of your Medicaid PACE Program Referral.