NM MAD 379 2018 free printable template
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New Mexico Human Services Department – Medical Assistance Division
Program of All-Inclusive Care for the Elderly (PACE) Long Term Care Medical Assessment
THIS INFORMATION IS CONFIDENTIAL
Initial
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...
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How to fill out NM MAD 379
01
Gather all necessary personal information including your name, address, and Social Security number.
02
Obtain the NM MAD 379 form from the New Mexico Human Services Department website or your local office.
03
Carefully read the instructions provided with the form.
04
Fill in your personal details accurately in the designated sections.
05
Provide any required documentation, such as income verification or proof of residency.
06
Review the completed form for any errors or missing information.
07
Submit the NM MAD 379 form to the appropriate agency office, either in person or by mail.
Who needs NM MAD 379?
01
Individuals applying for medical assistance programs in New Mexico.
02
Residents of New Mexico who need to report changes in their medical assistance eligibility.
03
Families seeking support for healthcare costs through state programs.
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What is NM MAD 379?
NM MAD 379 is a tax form used in New Mexico for the reporting of certain tax-related information.
Who is required to file NM MAD 379?
Individuals or entities who have specific tax obligations or are claiming certain tax credits in New Mexico are required to file NM MAD 379.
How to fill out NM MAD 379?
To fill out NM MAD 379, follow the instructions provided with the form, ensuring that all required fields are completed accurately and supporting documentation is attached.
What is the purpose of NM MAD 379?
The purpose of NM MAD 379 is to collect important tax data from filers to ensure compliance with New Mexico tax laws and to assess eligibility for specific tax credits.
What information must be reported on NM MAD 379?
Information that must be reported on NM MAD 379 includes taxpayer identification details, income information, tax deductions, credits being claimed, and any other relevant financial information required by the state.
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