Transfer Request Forms and Defective PA Forms
- Memo for Beneficiary Transfer Requests 09282016.pdf
- LTCA PA Request Notification 09282016.docx
- LTCA Defective PA Form (02032016) 07142016 Savable_final.pdf
- LTCA EPDW Transfer Form (02032016) 07142016 Savable_final.pdf
- LTCA State Plan Transfer Form (02032016) 07142016 Savable_Final.pdf
Form 719A Prior Authorization Request
Nursing Facility Forms
- PASRR Level 1 Form (Version May 2019) (PDF)
- Nursing Facility FAQ
- Attestation NF MD.pdf (Fillable Form)
- Attestation NF physician instruction sheet 7 10 17.docx
- Cover Page Out State Nursing Facility Placement (revised September 11, 2019) replace current cover page file (PDF)
- Proof of Contact (revised September 11, 2019) replace current proof of contact file (PDF)
- Beneficiary Agreement (revised September 11, 2019) (PDF)
- Request for Out of State Placement Form (revised September 11, 2019) (PDF)
- Eligibility Determination and Enrollment Process for EPD Waiver: Response to G.W. Health Insurance Counseling Project (HICP) Fact Sheet (PDF)
- District of Columbia Long-Term Care/Waiver Medicaid Application (2018)
- Retroactive Medicaid Application for Institutional Care (2018)
- Resource FAQ Sheet .pdf
- EPD FACT Sheet.pdf
- Financial Eligibility Institutional Care Fact Sheet.pdf
- Spend down FAQ Fact Sheet.pdf
POF: Prescription Order Form
RN Attestation Forms for Annual PCA Level of Need Recertifications
DME MADS Referral Form