Get Dmas 96

The Dmas 96 form is essential for authorizing Medicaid-funded long-term services and supports. This guide provides a comprehensive, step-by-step overview of how to complete this form online, ensuring users can navigate each section with confidence.

Follow the steps to successfully fill out the Dmas 96 online.

1. Press the 'Get Form' button to acquire the form and open it in the appropriate editor for completion.
2. Begin with the Individual Information section. Enter the last name, first name, birth date (MM/DD/YYYY format), Social Security number, and Medicaid ID number if applicable. Indicate the individual's sex by entering 'F' for female or 'M' for male.
3. Proceed to the Medicaid Eligibility Information section. Here, select if the individual is currently Medicaid eligible by marking '1' for yes, '2' if anticipated eligibility is within 180 days of nursing facility admission, or '3' if not expected to be eligible. If not eligible, indicate whether the individual has formally applied for Medicaid by selecting '0' for no or '1' for yes.
4. Next, determine Auxiliary Grant eligibility. Enter the appropriate code: '0' for no, '1' for yes or has applied, or '2' for no but eligible for General Relief. Provide the names of the local departments of social services responsible for eligibility and services, if known.
5. In the Pre-Admission Screening Information section, enter the Medicaid Authorization level of care based on the provided codes for the type of services required. Ensure that only one code is entered.
6. Indicate if any Medicaid services are authorized using the provided codes for various service options. Specify if targeted case management is needed and mark the appropriate ALF reassessment type.
7. Provide the name and number of the ALF provider, along with the admit date. Document service availability and the expected length of stay.
8. Complete the Level I/ALF Screening Identification by entering the name of the screening agency and their corresponding NPI/API number.
9. If applicable, fill out the Level II Assessment Determination section with the screener's name and their NPI/API number. Confirm if the individual expired after the screening decision.
10. Finally, all required signatures, including those of the Level I/ALF screener and physician, must be obtained and dated. Ensure accuracy in signing and dating these sections.
11. After completing the form, review all entries for accuracy, save the changes, and download, print, or share the completed Dmas 96 form as needed.

Complete your documents online with confidence by following these steps for the Dmas 96.