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Fill Out Your 3871 Maryland Medicaid Template

The 3871 Maryland Medicaid form is a crucial document used to assess an individual's eligibility for medical assistance services in Maryland. This form gathers essential information about the patient's demographics, medical history, and the level of care required. Completing this form accurately is vital for ensuring that individuals receive the appropriate support and services they need.

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Launch 3871 Maryland Medicaid Editor

Fill Out Your 3871 Maryland Medicaid Template

Article Structure

Dos and Don'ts

When filling out the 3871 Maryland Medicaid form, there are important steps to follow to ensure the process goes smoothly. Here’s a helpful list of things you should and shouldn’t do:

Do print or type clearly to avoid any confusion.
Do provide accurate and complete patient demographics.
Do ensure the physician’s plan of care is filled out thoroughly.
Do check for any changes in medications or treatments recently.
Don’t leave any sections blank unless instructed to do so.
Don’t use abbreviations that may not be understood by the reviewer.
Don’t forget to include the patient’s representative information if applicable.
Don’t submit the form without reviewing it for accuracy first.

By following these guidelines, you can help ensure that the application process for Maryland Medicaid goes as smoothly as possible.

Misconceptions

Understanding the 3871 Maryland Medicaid form can be challenging. Here are seven common misconceptions about this form, along with clarifications to help navigate its requirements.

Misconception 1: The form is only for nursing facilities.

This form is used for various levels of care, including medical day care, rehabilitation hospitals, and chronic hospitals. It is not limited to nursing facilities.

Misconception 2: Only physicians can fill out the form.

While a physician or their designee must complete the plan of care section, other healthcare providers may assist in gathering patient information and documentation.

Misconception 3: The form is not required for all patients.

Any patient seeking medical assistance through Medicaid must complete the 3871 form to determine eligibility for services.

Misconception 4: Completing the form guarantees Medicaid approval.

Filling out the form does not guarantee approval. Eligibility is determined based on the information provided and the specific requirements of the Medicaid program.

Misconception 5: The form can be submitted without supporting documentation.

Supporting documentation, such as a plan of care from the admitting hospital, is often necessary for processing the application and determining eligibility.

Misconception 6: The form only needs to be filled out once.

Patients may need to complete the form periodically, especially for renewals or changes in their medical condition or care needs.

Misconception 7: Language barriers do not affect the application process.

Language barriers can significantly impact communication. It is important to indicate if there are any language issues to ensure appropriate assistance is provided during the application process.

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Key takeaways

Here are some key takeaways regarding the completion and use of the 3871 Maryland Medicaid form:

Accurate Information is Essential: Ensure all sections of the form are filled out completely and accurately. This includes patient demographics, medical history, and the physician’s plan of care.
Language Considerations: Indicate if there are any language barriers that may affect communication. This information is crucial for understanding patient needs.
Physician's Role: The physician or their designee must complete the plan of care section. This includes detailing diagnoses and required interventions.
Functional and Cognitive Assessment: The form requires a thorough assessment of the patient’s functional and cognitive status. This includes their ability to perform daily activities and any behavioral issues.
Submission Requirements: The completed form must be submitted to the appropriate Medicaid authority. Ensure that any necessary supporting documents, such as the plan of care for rehabilitation, are included.

Guidelines on Utilizing 3871 Maryland Medicaid

Completing the 3871 Maryland Medicaid form is a vital step in ensuring that individuals receive the necessary medical assistance they need. This form requires specific information about the patient, their medical condition, and the services being requested. It's important to gather all relevant details before starting to fill out the form to make the process smoother.

Gather Required Information: Collect all necessary details such as the patient’s name, Social Security number, and medical history.
Complete Patient Demographics: Fill in the patient’s last name, first name, date of birth, sex, and admission date. Provide the permanent address and the name of the last provider.
Specify the Level of Care: Indicate the level of care or services being requested by checking the appropriate box (e.g., NF, Medical Day Care, Rehab Hospital).
Document the Physician’s Plan of Care: This section must be filled out by a physician or their designee. Include the physician’s name, contact information, primary and secondary diagnoses, and any pertinent findings.
Record Patient Vital Signs: Include information about the patient’s vital signs and any significant changes. Note if the patient is free from infection.
Detail Medications and Treatments: List any medications that will be continued, along with their dosage, frequency, and route. Describe any ongoing treatments.
Assess Functional Status: Use the provided codes to indicate the patient’s functional abilities in areas such as locomotion, dressing, and eating.
Evaluate Cognitive and Behavioral Status: Check the appropriate boxes to assess the patient's cognitive skills, communication abilities, and any behavior issues.
Complete Pediatric Functional Status (if applicable): For patients under 21, fill out the functional and cognitive status section specific to pediatric needs.
Physician’s Certification: The physician must certify the need for the specified level of care by signing and dating the form.
Final Review: Double-check all entries for accuracy and completeness before submitting the form.

Once the form is completed, it will need to be submitted to the appropriate Medicaid office for review. Make sure to keep a copy for your records, as this can be helpful for any follow-up or additional information requests.

Form Preview Example

Maryland Medical Assistance Program

Medical Eligibility Review Form PLEASE PRINT OR TYPE

Level of Care/Services Requested (application for rehab	Application Date: ________________________
hospitals must be accompanied by a plan of care from admitting	Financial Eligibility Date:__________________
hospital) (Please check)	Social Security #:_________________________
	Medical Assistance #:_____________________
 Chronic Hospital* Model Waiver*

(If patient is on a ventilator, please use the DHMH 3871B with the Ventilator Questionnaire)

Part A: Patient Demographics

Patient’s Last Name: ____________________________________	Patient’s First Name: _______________________
Patients Date of Birth: __________ Sex: ____Adm. Date: ________
Permanent Address: ____________________________________
_____________________________________________________	Name of Last Provider (Hospital, Long Term Care Facility)
Present location of Patient: (if different from above)	Institution: ___________________________________
______________________________________________________	Admission Date: _______________________________
______________________________________________________	Discharge Date: _______________________________
Patient’s Representative Name: ____________________________	Relationship to Patient: _________________________
Representative Phone #: __________________________________	Representative Address: ________________________
Is language a barrier to communication ability? ___YES ___NO	____________________________________________

****************************************************************************************************************

Part B: Physician’s Plan of Care (Must be completed by physicians or designee)

Please fill out accurately and completely

Physicians Name: ____________________________ Telephone #: _________________ Address: ______________________

Primary Diagnoses which relate to need for level of care: _______________________________________________________

Secondary/Surgical Diagnoses currently requiring M.D. and/or Nursing intervention which relates to level of care:

__________________________________________________________________________________________ Date: ________

Other pertinent findings (ex. Signs and symptoms, complications, lab results, etc… ____________________________________

_______________________________________________________________________________________________________

_____________________________________________________________________________________________

Is patient free from infection TB? ____YES ____ NO Determined by: ___ Chest X-Ray ___PPD Date: ___________________

T __________ P __________ R ___________ B/P __________ HT __________ WT __________

Have any of the above vital signs undergone a significant change? ___YES ___NO If Yes explain: _____________________

_______________________________________________________________________________________________________

Diet (Include supplements and tube feeding solution) ___________________________________________________________


DHMH 3871 rev. 4/95	Medical Review Form	Page 1 of 4

Patient’s Name: ______________________________

Medication which will be continued:

Medication

Dosage

Frequency

Route

If PRN, avg frequency

Treatment which will be continued: DescriptionFrequencyDuration if Temporary

____ Ventilator: ____________________________________________________________________________________

____ O2 (as well as sats and frequency): _________________________________________________________________

____ Monitor (apnea/bradycardia (A/B), other: ___________________________________________________________

____ Suctioning: ____________________________________________________________________________________

____ Trach Care: ____________________________________________________________________________________

____ IV Line/fluids (indicate central or peripheral): _________________________________________________________

____ Tube Feeding (specify type of tube): ________________________________________________________________

____ Colostomy/ileostomy care: _______________________________________________________________________

____ Catheter/continence device (specify type): __________________________________________________________

____ Frequent labs related to nutrition/needs (describe): ___________________________________________________

____ Decubitus (include size, location, stage, drainage, and signs of infection, also Tx regimen): _____________________

__________________________________________________________________________________________________

____ Other (specify): ________________________________________________________________________________

__________________________________________________________________________________________________

Have any medications or treatments recently been implemented, discontinued, and/or otherwise changed? Explain:

_______________________________________________________________________________________________________

_______________________________________________________________________________________________

Impairments/devices (check all that apply) ___Speech ___Sight ___Hearing ___Other (specify) ______________________

___Devices/Adaptive Equipment ________________________________________________________________________

Active Therapy

Plan

Frequency

Est. Duration

Goal

Physical Therapy

Occupational Therapy

Speech Therapy

Respiratory

Others


DHMH 3871 rev. 4/95	Medical Review Form	Page 2 of 4

Patient’s Name: 5674

Rehabilitation Potential: ______________________________________________________________________________

Discharge Plan: _____________________________________________________________________________________

*If requesting a level of care for rehab hospital, please answer the following questions:

1.Preexisting condition related to current physical, behavioral and mental functions and deficits: __________________

__________________________________________________________________________________________________

2.Reason for out-of-state placement (if applicable): ______________________________________________________

Is patient comatose? ___YES ___NO if yes skip parts C through E and go directly to part F.

PLEASE NOTE: For other adults applicants, complete parts C and D, skip E. For applicants under age 21, skip parts C and D, complete E.

*************************************************************************************************

	Part C: Functional Status (Use one of the following codes)
	(If assistive device (e.g., Wheelchair, Walker) used, note functional ability while using device)
0.	Little or no difficulty (completely independent	2.	Limited physical assistance by caregiver
	or setup only is needed	3.	Extensive physical assistance by caregiver
1.	Supervision/Verbal cuing	4.	Total dependence on others
___ Locomotion (if using adaptive/assistive device,		___ Dressing
Specify type): _____________________________		___ Bathing
___ Transfer bed/chair		___ Eating
___ Reposition/Bed mobility		Appetite (Check one): ___ Good ___ Fair ___ Poor

Other functional limitations (describe) ______________________________________________________________________

Incontinence management (Circle applicable choices in each category) (Note status with toileting program and/or continence device, if applicable)

Bladder			Bowel
0			0			Complete control-or infrequent stress incontinence
1			1			Usually continent-accidents once a week or less
2			2			Occasionally incontinent- accidents 2+ weekly, but not daily
3			3			Frequently incontinent- accidents daily but some control present
4			4			Incontinent- Multiple daily accidents
			*******************************************************************************************************
							Part D: Cognitive/Behavioral Status
1. Memory/orientation				Y=Yes	N=No		2. Cognitive skills for daily life decision making and safety (Check one)
Yes	No
___	___	Can recall after 5 minutes					___	Independent decisions consistent and reasonable
___	___	Knows current season					___	Modified/some difficulty in new situations only
___	___	Knows own name					___	Moderately impaired/decisions requires cues/supervision
___	___	Can recall long past events					___	Severely impaired/rarely or never makes decisions
___	___	Knows present location
___	___	Knows family/caretaker

3. Communication		0- Always	1-Usually	2-Sometimes 3-Rarely
Ability to understand others		_____	_____	_____	____
Ability to make self understood		_____	_____	_____	____
Ability to follow simple commands		_____	_____	_____	____


DHMH 3871 rev. 4/95	Medical Review Form				Page 3 of 4

Patient’s Name ____________________________________
4. Behavior issues (enter one code from A and B in the appropriate column)
A. Frequency	B. Easily Altered
1= Occasionally	1= Yes
2=Often, but not daily	2= No
3= Daily

	Description of Problem Behaviors	A	B

5.Most recent mini-mental score ___________________________________ Date: __________________________

Previous mini-mental score ______________________________________ Date: __________________________

*******************************************************************************************************

Part E: Functional/Cognitive Status – Pediatric

		Age Appropriate		Functioning Level	Adaptive Equipment
	Cognition				Wheelchair
	Social Emotional				Splints/Braces
	Behavior				Side Lyer
	Communications				Walker
	Gross Motor Abilities				Adaptive Seating
	Fine Motor Abilities				Communication Devices
	Feeding				Other
	Toileting
	Self Care
		Part F: Physician’s Certification for Level of Care
This patient is certified as in need of the following services (Check One):
	Chronic Hospital		Model Waiver

Other information pertinent to need for Long Term Care: _________________________________________________________

Physician’s Signature: ___________________________________________________________ Date: _____________________

Other than physician completing form: ________________________________________________________________________

SignatureTitlePhoneDate

**********************************************************************************************************

This area is for Agent Determination Only. DO NOT write in this area.

		Renewal
___ Medical Eligibility Established	MD Advisor ___	___Medical Eligibility Established	MD Advisor___
___ Medical Eligibility Denied		___ Medical Eligibility Denied
Effective Date: _____________________		Effective Date: _____________________
Type of Service: _________________________________		Type of Service: __________________________________
Certificate Period: From: _____________ To: ___________		Certificate Period: From: _____________ To: ___________
Agent Signature: _________________________________		Agent Signature: __________________________________
Date: ___________________________________________		Date: ___________________________________________


DHMH 3871 rev. 4/95	Medical Review Form	Page 4 of 4

Common mistakes

Not using black ink or typing the information can lead to readability issues. Always print or type clearly.
Forgetting to sign and date the form can delay processing. Make sure all required signatures are included.
Leaving sections blank can result in incomplete applications. Fill out every section that applies to the patient.
Not providing accurate contact information for the patient representative can create communication problems. Ensure phone numbers and addresses are correct.
Failing to check the language barrier question can lead to misunderstandings. Be honest about communication needs.
Not including a plan of care from the admitting hospital when required can result in denial. Always attach necessary documents.
Missing the admission and discharge dates can cause confusion. Double-check these dates for accuracy.
Forgetting to list all medications and treatments may affect eligibility. Provide a complete list with dosages and frequencies.
Not answering all functional status questions can lead to an incomplete assessment. Be thorough in describing the patient’s abilities.
Ignoring the physician's plan of care section can result in insufficient information. Ensure this part is filled out by a qualified medical professional.

Free 3871 Maryland Medicaid PDF

Learn More on This Form

What is the purpose of the 3871 Maryland Medicaid form?

The 3871 Maryland Medicaid form, also known as the Medical Eligibility Review Form, is used to assess an individual's eligibility for medical assistance services in Maryland. This form collects essential information about the patient's demographics, medical history, and the level of care required. It plays a critical role in determining whether an individual qualifies for services such as nursing facilities, rehabilitation hospitals, or medical day care.

Who is responsible for completing the form?

The form must be completed by a physician or a designated representative. It requires detailed medical information, including diagnoses, treatment plans, and any other relevant findings. The physician's signature is necessary to certify that the patient meets the criteria for the requested level of care. This ensures that the information is accurate and reflects the patient's current medical status.

What information is required in the patient demographics section?

The patient demographics section requires the patient's full name, date of birth, sex, social security number, and medical assistance number. Additionally, it asks for the patient's permanent address, current location, and the name of the last provider or facility. This information is crucial for identifying the patient and ensuring that their case is managed appropriately.

What types of services can be requested using this form?

The 3871 form allows for the request of various services, including nursing facility care, medical day care, rehabilitation hospital care, and chronic hospital services. It is essential to indicate the specific level of care being requested, as this will guide the evaluation process and determine the eligibility for those services.

How does the form assess the patient's functional status?

The form includes a section dedicated to evaluating the patient's functional status. It uses a coding system to gauge the level of assistance the patient requires in daily activities, such as locomotion, dressing, and eating. Additionally, it assesses cognitive skills and communication abilities. This comprehensive assessment helps determine the appropriate level of care tailored to the patient's needs.

What happens after the form is submitted?

Once the 3871 form is completed and submitted, it undergoes a review by a designated agent. They will evaluate the information provided to determine medical eligibility for the requested services. The outcome will be communicated to the applicant, and if approved, a certificate period will be established. If denied, the applicant will receive an effective date for the denial, along with information on potential next steps.