3871 form-2026

The document is a Maryland Medical Assistance Program Medical Eligibility Review Form, used to assess patient eligibility for various levels of medical care, including rehabilitation hospitals and nursing facilities. It includes sections for patient demographics, physician's plan of care, functional and cognitive status assessments, and certification of need for services. The form requires detailed information about the patient's medical history, current treatments, and functional abilities to determine appropriate care.

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Click ‘Get Form’ to open the 3871 form in the editor.
Begin with Part A: Patient Demographics. Fill in the patient's last name, first name, date of birth, and sex. Ensure you provide the admission date and verbal level of care given.
Next, complete the financial eligibility section by entering the application date, social security number, and medical assistance number.
In Part B: Physician’s Plan of Care, have a physician fill out their name, telephone number, and address. Document primary and secondary diagnoses that relate to the need for level of care.
Continue through Parts C to E by assessing functional status and cognitive/behavioral status. Use the provided codes to indicate levels of assistance needed.
Finally, ensure that Part F is completed with the physician's certification for level of care before submitting your form.

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