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Medical assessment form 2026

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The document outlines the Long Term Care Medical Assessment (MAD 379) used by the New Mexico Human Services Department's Medical Assistance Division for the Program of All-Inclusive Care for the Elderly (PACE). It details the process for assessing patients' eligibility for Nursing Facility Level of Care (NF LOC), including patient information, activities of daily living (ADL) assessments, and provider attestations. The completed assessment is reviewed by a Third Party Assessor to determine if the patient meets state criteria for NF LOC, ensuring all information remains confidential.

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Click ‘Get Form’ to open the medical assessment form in the editor.
Begin with Section A: General Patient Information. Fill in the patient's name, Medicaid number or SSN, date of birth, mailing address, and phone number. If applicable, include the authorized representative's details.
Move to Section B: Activities of Daily Living (ADL). Assess each activity and check either 'Independent' or 'Assistance Required to Complete' based on the patient's needs.
Proceed to Section C: Provider Information & Attestation. Enter your printed name, provide your signature (original or electronic), and complete your physical address and contact information.
If applicable, Section D is for TPA Utilization Review. This section will be completed by the TPA; ensure all necessary information is provided for their review.

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Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (148 Votes)
2018	4.4 Satisfied (168 Votes)
2014	4.4 Satisfied (162 Votes)
2011	4.4 Satisfied (47 Votes)

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