Mad378 2025

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The document outlines the Long Term Care Medical Assessment form (MAD 378) used in the Medicaid program to evaluate and authorize care for individuals with intellectual disabilities. It includes sections for patient information, medical assessments, and documentation requirements necessary for determining eligibility for Intermediate Care Facility (ICF/IID) services or Home and Community-Based Services (HCBS). The assessment is conducted by medical providers and reviewed by a Third Party Assessor to ensure compliance with state criteria.

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Click ‘Get Form’ to open the mad378 in the editor.
Begin with Section A: General Patient Information. Fill in the 'Assessment Type' by selecting from options like 'Initial', 'Continued Stay/Annual', or others as applicable. Enter the patient's name, date of admission, and Medicaid eligibility status.
Proceed to Section B: General Facility Information. Input the facility's name, mailing address, provider number, and contact details. Ensure all fields are accurately completed for effective communication.
In Section C: Medical Assessment, document the patient's diagnosis and medications. List assessment factors indicating specialized services needed and provide scores based on the criteria outlined.
Finally, review all sections for completeness before submitting. Ensure that any required supporting documentation is attached.

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Versions	Form popularity	Fillable & printable
2015	4.8 Satisfied (120 Votes)

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