MD Statewide Medical Assistance Transportation Transfer/Discharge Form 2018-2025 free printable template
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Carroll County Department of Health Medical Assistance Transportation Program 290 S. Center Street, Westminster, MD 21157 PHONE: (410) 8764813 FAX: (410) 8764957 MARYLAND STATEWIDE MEDICAL ASSISTANCE
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How to fill out MD Statewide Medical Assistance Transportation TransferDischarge
How to fill out MD Statewide Medical Assistance Transportation Transfer/Discharge Form
01
Obtain the MD Statewide Medical Assistance Transportation Transfer/Discharge Form from the appropriate health or transportation agency.
02
Fill out the patient's personal information at the top of the form, including name, address, and contact details.
03
Indicate the date of the transfer or discharge.
04
Specify the reason for transportation, whether it’s for discharge to home or to another facility.
05
Provide the details of the current medical facility, including name, address, and contact number.
06
List the destination facility's information if applicable, including name, address, and contact number.
07
Include details regarding the patient's medical condition and any special transportation needs.
08
Sign and date the form as required, and ensure that all sections are completed accurately.
09
Submit the completed form to the transportation provider or agency overseeing the medical assistance program.
Who needs MD Statewide Medical Assistance Transportation Transfer/Discharge Form?
01
Individuals receiving medical assistance through Maryland’s Medicaid program who are being transferred or discharged from a medical facility.
02
Healthcare providers responsible for arranging transportation for patients in need of medical assistance.
03
Family members or guardians of patients requiring transportation assistance during a transfer or discharge process.
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What is MD Statewide Medical Assistance Transportation Transfer/Discharge Form?
The MD Statewide Medical Assistance Transportation Transfer/Discharge Form is a document used to facilitate the transportation of medical assistance recipients when they are being transferred or discharged from a healthcare facility.
Who is required to file MD Statewide Medical Assistance Transportation Transfer/Discharge Form?
Healthcare providers or facilities that are responsible for the transfer or discharge of a medical assistance recipient are required to file the MD Statewide Medical Assistance Transportation Transfer/Discharge Form.
How to fill out MD Statewide Medical Assistance Transportation Transfer/Discharge Form?
To fill out the MD Statewide Medical Assistance Transportation Transfer/Discharge Form, you need to provide information about the patient, the facility, the reason for transfer or discharge, transportation details, and any special instructions necessary for the safe transportation of the patient.
What is the purpose of MD Statewide Medical Assistance Transportation Transfer/Discharge Form?
The purpose of the MD Statewide Medical Assistance Transportation Transfer/Discharge Form is to ensure that medical assistance recipients receive appropriate transportation during transfers or discharges, and to document the details surrounding these processes to ensure compliance and proper care.
What information must be reported on MD Statewide Medical Assistance Transportation Transfer/Discharge Form?
The information that must be reported on the MD Statewide Medical Assistance Transportation Transfer/Discharge Form includes the patient's name, medical assistance number, the transferring facility's information, the receiving facility's information, the reason for transfer or discharge, transportation requirements, and contact information for follow-up.
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