Reassessment Date Current LOC Expires: A. General Patient Information 1. Patient Name (First, Middle Initial, Last): 2. Medicaid No. or SSN: 3. Date of Birth (00/00/0000): 4. Patient Mailing Address (Address, City, State, Zip Code): 5. Patient Phone #: 6. Authorized Representative Name (First and Last): 7. Representative Mailing Address (Address, City, State, Zip Code): 8. Representative Phone #: B. Activities of Daily Living (ADL) - Patient must meet Nursing Facility Level.
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How to fill out the NM MAD 379 online
Completing the NM MAD 379 online is an important step in the process of obtaining medical assistance for long-term care. This guide offers clear and supportive instructions to help you through each component of the form, ensuring that you provide all necessary information accurately.
Follow the steps to complete the NM MAD 379 form online.
- Click ‘Get Form’ button to access the NM MAD 379 document and open it in your preferred editor.
- Begin with Section A, General Patient Information. Enter the patient's full name, Medicaid number or Social Security number, date of birth, mailing address, and phone number. If there is an authorized representative, provide their name, address, and phone number as well.
- Proceed to Section B, Activities of Daily Living. Assess and indicate the patient’s ability to perform daily activities by checking either 'Independent' or 'Assistance Required to Complete' for each activity listed.
- Move to Section C, Provider Information & Attestation. Enter the provider's printed name, signature (original or electronic), completion date, physical address, phone number, and fax number. Ensure that you acknowledge the electronic signature policy.
- If applicable, fill out Section D, TPA Utilization Review Section. Note that this section will typically be completed by the Third Party Assessor.
- Once all sections are filled out completely and accurately, you can save your changes, download the completed form, print it, or share it as needed.
Start filling out your NM MAD 379 online today to expedite the process of obtaining necessary medical assistance.
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