DMA-5048-2026

1. Click ‘Get Form’ to open the DMA-5048 in the editor.
2. Begin with Section 1, where you will enter identifying information. Fill in the County Department of Social Services, date, beneficiary name, address, date of birth, Medicaid ID, phone number, caseworker name, and caseworker phone.
3. Move to Section 2 for Medicaid Beneficiary Consent. Enter the beneficiary's name and authorize a medical provider to release necessary information by filling in their details. Ensure the signature and date are completed.
4. In Section 3, specify the exception requested and justification. Indicate if transportation is needed to a distant provider or if special accommodations are required. Provide detailed explanations as prompted.
5. Complete Section 4 by having the provider print their name, phone number, and sign with the date to attest that all statements are true.

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