Dhmh 4245 form-2026

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The document is a Maryland Medical Assistance Program Physician Report, which includes sections for identifying an institutionalized person and a statement by the attending physician regarding the patient's anticipated length of stay in a long-term care facility, medical reasons for this expectation, and required support systems for community living. It also contains a notice to Medicaid applicants about the importance of providing personal information for eligibility determination.

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Click ‘Get Form’ to open the dhmh 4245 form in the editor.
Begin with Part I, where you will enter the institutionalized person's identification details. Fill in the name, CID#, facility name, and contact information as required.
Next, provide the representative's name and contact details in section 3, followed by the case manager's information in section 4.
Move to Part II and check the appropriate box regarding the anticipated length of stay for the patient. If applicable, specify the expected discharge month and year.
In section 2 of Part II, detail the medical reasons supporting your expectation. Use additional space if necessary.
Indicate any support systems needed for community living in section 3. Check all that apply or specify other needs.
Finally, sign and print your name as the attending physician, along with your date and address at the bottom of Part II.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What documents do you need to apply for Maryland Medicaid?

How to Submit a Fee-for-Service Claim Sign up for eMedicaid to submit single claims electronically. Mail paper claim submissions to the Claims Processing Division. Enroll in Maryland Medicaid Electronic Exchange testing to submit Electronic Data Interchange (EDI) transactions.

What is the monthly income limit for Medicaid in MD?

What documents do I need to apply? Birthdates. Social Security Numbers (or document numbers for legal immigrants) Citizenship or immigration status. Tax returns for previous years. Employer and income info (pay stubs, W-2 forms)

What is the maximum income to qualify for Medicaid in Maryland?

For most states, the Medicaid income limit is $2,901 per month for a single applicant and $5,802 per month for married applicants, typically set at 300% of the Federal Benefit Rate (FBR).