Get Nm Mad 379 2014

The NM MAD 379 form is a crucial document used for assessing eligibility for the Program of All-Inclusive Care for the Elderly (PACE). This guide will provide you with comprehensive, step-by-step instructions to assist you in accurately completing the form online.

Follow the steps to fill out the NM MAD 379 online effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In the General Patient Information section, input the patient’s name (first, middle initial, last) in the first field. In the second field, enter either the patient’s Medicaid number or Social Security number. Next, fill in the patient’s date of birth in the format 00/00/0000.
3. Continue completing the General Patient Information by providing the patient’s mailing address, including the address, city, state, and zip code. Then, enter the patient’s phone number.
4. In the subsequent fields, enter the authorized representative’s first and last name, followed by their mailing address and phone number, ensuring all information is accurate.
5. Move to the Activities of Daily Living (ADL) section. For each listed activity, assess the patient's needs and check the box for either 'Independent' or 'Assistance Required to Complete' as appropriate.
6. In the Provider Information & Attestation section, input the provider’s printed name and signature (either original or electronic). In addition, fill in the date of completion of the MAD 379 form and provide the provider’s physical address, phone number, and fax number.
7. The TPA Utilization Review Section will be completed by the Third Party Assessor and does not require action from the user. They will fill in their initials, review details, and provide the review status.
8. After all sections have been completed accurately, save the changes made to the form. Users can also download, print, or share the form as necessary.

Complete your NM MAD 379 online today to ensure timely assistance for those in need.