Get Rem Application Maryland

Filling out the Rem Application Maryland is a crucial process for individuals seeking assistance with rare and expensive diseases. This guide provides clear, step-by-step instructions for completing the application efficiently and accurately.

Follow the steps to complete the Rem Application Maryland online.

1. Click the ‘Get Form’ button to access the application, allowing you to fill it out electronically.
2. Start with the referral source section on Page 1. Provide the referral source's name, address, telephone number, and fax number.
3. Next, complete the patient information fields. This includes the patient's first name, middle initial, last name, Medical Assistance number, complete address (including apartment number if applicable), date of birth, telephone numbers, sex, and Social Security Number.
4. Fill in the Managed Care Organization (MCO) information, including the MCO name, contact person, and their phone number if available.
5. Provide patient contact information, which could be the patient themselves or a family member, such as a parent, guardian, or partner. Include their complete address, telephone numbers, and relationship to the patient.
6. In the referring provider section, enter the provider's name, specialty, license number, and contact number. Remember to get the provider's signature and add information for any consulting physicians, including their specialties and phone numbers.
7. On Page 2, write the patient’s name and date of birth at the top. Fill out the clinical information section by listing primary and secondary diagnoses, along with the corresponding ICD-10 codes.
8. Complete the supporting information section with relevant medical documentation, ensuring to follow the REM disease guidelines.
9. A physician's signature is required at the bottom of page 2. Once complete, you can fax the form and all supporting information to the REM Intake Unit or mail it to the provided address.
10. After filling out all sections, review the form for accuracy, then choose to save changes, download, print, or share the completed form as needed.

Complete your Rem Application Maryland online today for a seamless experience.