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Fill a Valid Georgia Dma 6 Template

The Georgia DMA 6 form is a crucial document used to assess the medical needs of children applying for Medicaid coverage in nursing facilities. It requires detailed information about the applicant, including personal details, medical history, and recommendations from a physician. Understanding this form is essential for families navigating the Medicaid application process for pediatric care.

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Article Structure

Common mistakes

Failing to provide complete identifying information. All sections, including the applicant's name, address, Medicaid number, and Social Security number, must be filled out accurately.
Not including the correct birthdate. It is essential to enter the applicant's birthdate to avoid delays in processing.
Omitting the primary care physician's information. This information is critical for coordinating care and verifying medical history.
Inaccurately answering questions regarding the applicant's school attendance and institutionalization. These answers must reflect the current situation to ensure appropriate care recommendations.
Not signing or dating the authorization section. The signature of the parent or legal representative is necessary for the form to be valid.
Failing to attach required documentation, such as medical records or additional sheets for history and diagnosis. This can lead to incomplete evaluations.
Leaving out details about medications and treatment plans. Accurate medication information is crucial for assessing the applicant's needs.
Not checking the appropriate boxes in the evaluation of nursing care needed section. This oversight can misrepresent the level of care required.
Providing incomplete or inaccurate physician information, including licensure number and contact details. This information is necessary for follow-up and verification purposes.

Essential Points on This Form

What is the Georgia DMA 6 form?

The Georgia DMA 6 form is a document used for the Medicaid eligibility determination process for children who require nursing facility care. It collects essential information about the applicant, including medical history, diagnosis, and the level of care needed.

Who needs to fill out the DMA 6 form?

This form must be completed by a physician who is familiar with the applicant's medical condition. It is intended for children who may need institutional care or specialized services under Medicaid programs such as GAPP, TEFRA, or Katie Beckett.

What information is required in Section A of the DMA 6 form?

Section A requires identifying information about the applicant, including their name, address, Medicaid number, Social Security number, age, and birthdate. It also asks for the primary care physician's details and whether the guardian believes the applicant should be institutionalized.

What should be included in Section B of the DMA 6 form?

Section B focuses on the physician's report and recommendation. It includes the applicant's medical history, diagnoses, medications, treatment plans, and anticipated dates of hospitalization. Physicians should also indicate the recommended level of care and whether the applicant's condition can be managed with community care or home health services.

How does the DMA 6 form support Medicaid eligibility determination?

The DMA 6 form provides the necessary medical documentation to support a child's application for Medicaid services. The information collected helps the Department of Community Health and the Department of Human Resources assess the applicant's medical needs and eligibility for coverage.

What happens if the form is incomplete or inaccurate?

If the DMA 6 form is incomplete or contains inaccuracies, it may delay the eligibility determination process. It is crucial to ensure that all sections are filled out accurately and completely to avoid any complications.

How long is the authorization for disclosure of medical records valid?

The authorization for the disclosure of protected health information is valid for twelve months from the date it is signed or until it is revoked by the legal representative, whichever comes first.

What is the significance of the physician's signature on the DMA 6 form?

The physician's signature on the DMA 6 form certifies that the information provided is accurate and that the applicant requires the level of care specified. This endorsement is essential for the Medicaid application process.

Can additional information be attached to the DMA 6 form?

Yes, additional sheets can be attached to provide more detailed medical history, diagnoses, or treatment plans. This information can help clarify the applicant's needs and support the eligibility determination.

What should be done after completing the DMA 6 form?

Once the DMA 6 form is completed, it should be submitted to the appropriate Medicaid agency along with any other required documentation. It is advisable to keep a copy for personal records.

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Georgia Dma 6 Sample

						Type of Program:	Nursing Facility
							GAPP
							TEFRA/Katie Beckett
			PEDIATRIC DMA 6(A)
		PHYSICIAN’S RECOMMENDATION FOR PEDIATRIC CARE
Section A – Identifying Information
1.	Applicant’s Name/Address:			2.	Medicaid Number:		3. Social Security Number

							4. Sex	Age		4A. Birthdate
					----------------------------------------
	DFCS County_____________________
	DFCS County_____________________			5.	Primary Care Physician
				5.	Primary Care Physician
	___________________________________________
	___________________________________________			6.	Applicant’s Telephone #
	Mailing Address			6.	Applicant’s Telephone #
	Mailing Address
7.	Does guardian think the applicant should be institutionalized?			8.	Does child attend school?		9. Date of Medicaid Application
	Yes	No			Yes	No		/	/
Name of Caregiver #1: _______________________________			Name of Caregiver #2: ______________________________

I hereby authorize the physician, facility or other health care provider named herein to disclose protected health information and release the medical records of the applicant/beneficiary to the Department of Community Health and the Department of Human Resources, as may be requested by those agencies, for the purpose of Medicaid eligibility determination. This authorization expires twelve (12) months from the date signed or when revoked by me, whichever comes first.

10. Signature:___________________________________________________________________	11. Date:__________________________
(Parent or other Legal Representative)

Section B – Physician’s Report and Recommendation

12.

History: (ATTACH ADDITIONAL SHEET IF NEEDED)

1. ICD

2. ICD

3. ICD

13.

Diagnosis

1)_______________________________ 2)_______________________________ 3)_____________________________

(Add attachment for additional diagnoses)

14.

Medications

15.

Diagnostic and Treatment Procedures

Name

Dosage

Route

Frequency

Type

Frequency

16.

Treatment Plan (Attach copy of order sheet if more convenient or other pertinent documents)

Previous Hospitalizations:____________________________ Rehabilitative Services:__________________________ Other Health Services:_________________________

Hospital Diagnosis: 1)_________________________________ 2) Secondary______________________________ 3) Other_____________________________________

17. Anticipated Dates of Hospitalization:

__________/________

18.

Level of Care Recommended:

Hospital

Nursing Facility

IC/MR Facility

19.

Type of Recommendation:

20. Patient Transferred from (check one):

21. Length of Time Care Needed _____Months

22. Is patient free of

Initial

Hospital

Another NF

Permanent

communicable diseases?

Change Level of Care

Private Pay

Lives at home

Temporary _______ estimated

Yes

Continued Placement

23.

This patient’s condition

could

could not be managed by

24. Physician’s Name (Print):

provision of

Community Care or

Home Health Services

Physician’s Address (Print):

25.

I certify that this patient requires the level of care provided

26. Date signed by Physician

27.

Physician’s Licensure No.

28. Physician’s Telephone #:

by a nursing facility, IC/MR facility, or hospital

(

)

______________________________________Physician’s Signature

Section C– Evaluation of Nursing Care Needed (check appropriate box only)

29.

Nutrition

30.

Bowel

31. Cardiopulmonary Status

32.

Mobility

33.

Behavioral Status

Regular

Age Dependent

Monitoring

Prosthesis

Agitated

Diabetic Shots

Incontinence

CPAP/Bi-PAP)

Splints

Cooperative

Formula-Special

Incontinent - Age > 3 years

CP Monitor

Unable to ambulate >

Alert

Tube feeding

Colostomy

Pulse Ox

18 months old

Developmental Delay

N/G-tube/G-tube

Continent

Vital signs > 2/days

Wheel chair

Mental Retardation

Slow Feeder

Other ________________

Therapy

Normal

Behavioral Problems

FTT or Premature

Oxygen

(please describe, if checked)

Hyperal

Home Vent

Suicidal

IV Use

Trach

Hostile

Medications/GT

Nebulizer Tx

Meds

Suctioning

Chest - Physical Tx

Room Air

34.

Integument System

35.

Urogenital

36.

Surgery

37.

Therapy/Visits

38.

Neurological Status

Burn Care

Dialysis in home

Level 1 (5 or > surgeries)

Day care Services

Deaf

Sterile Dressings

Ostomy

Level II (< 5 surgeries)

High Tech - 4 or more

Blind

Decubiti

Incontinent – Age > 3 years

None

times per week

Seizures

Bedridden

Catheterization

Low Tech – 3 or less times

Neurological Deficits

Eczema-severe

Continent

per week or MD visits > 4

Paralysis

Normal

per month

Normal

None

39.

Other Therapy Visits

40.

Remarks

Five days per week

Less than 5 days per week

41.

Pre-Admission Certification Number

42.

Date Signed

43. Print Name of MD or RN:_____________________________

Signature of MD or RN:_______________________________

DO NOT WRITE BELOW THIS LINE

44.

Continued Stay Review Date:

Admission Date ___________________ Approved for ______________Days or ___________Months

45.

Are nursing services, rehabilitative services or other health related services

46A. State Authority MH & MR Screening)

requested ordinarily provided in an institution?

Yes

Level I/II

Restricted Auth. Code

Date

46B. This is not a re-admission for OBRA purposes

47.

Hospitalization Precertification

Met

Not

Met

Restricted Auth. Code

Date

48.

Level of Care Recommended by Contractor

Hospital

Nursing Facility

IC/MR Facility

49.

Approval Period

50. Signature (Contractor)

51. Date

52. Attachments (Contractor)

________________

Yes

DMA-6A (10/2004)

Key takeaways

Filling out the Georgia DMA 6 form is an important step for families seeking Medicaid assistance for pediatric care. Here are some key takeaways to keep in mind:

Identifying Information: Ensure that all personal details, including the applicant’s name, address, Medicaid number, and Social Security number, are accurately filled out. This information is crucial for processing the application.
Physician's Recommendation: The form requires a physician's report and recommendation, which includes the applicant's medical history and diagnosis. This section is vital for establishing the medical necessity for the requested care.
Authorization for Disclosure: The form includes an authorization section that allows healthcare providers to share the applicant's medical records with the Department of Community Health. This is necessary for Medicaid eligibility determination.
Caregiver Information: It is important to list the names of caregivers involved in the applicant's care. This information helps Medicaid understand the support system in place.
Level of Care: Clearly indicate the level of care recommended, whether it be a hospital, nursing facility, or other types of care. This recommendation guides the Medicaid decision-making process.
Anticipated Hospitalization: If applicable, provide anticipated dates for hospitalization. This helps in planning and ensuring that necessary services are available when needed.
Evaluation of Nursing Care: The form includes a section to evaluate the nursing care needed. Check all relevant boxes to accurately describe the applicant’s condition and care requirements.
Signatures and Dates: Don’t forget to include the signature of the parent or legal representative, along with the physician’s signature. Both signatures are essential for the application to be valid.

Completing the Georgia DMA 6 form accurately and thoroughly can significantly impact the outcome of the Medicaid application. Take your time to ensure that all information is correct and complete.

Document Characteristics

Fact Name	Description
Form Purpose	The Georgia DMA 6 form is used to recommend pediatric care for applicants needing nursing facility services under Medicaid.
Governing Law	This form operates under Georgia Medicaid regulations, specifically the Georgia Department of Community Health guidelines.
Applicant Information	Section A requires identifying information such as the applicant's name, address, Medicaid number, and social security number.
Physician's Role	A physician must complete the form, providing a recommendation and medical history to support the applicant's need for care.
Authorization	The form includes an authorization section allowing the disclosure of protected health information to relevant health agencies.
Caregiver Information	It requires the names and contact information of caregivers involved in the applicant's care.
Diagnosis Documentation	Physicians must document the applicant's diagnoses using ICD codes, which are critical for Medicaid eligibility.
Evaluation of Care Needs	Section C evaluates the nursing care needed, including nutrition, mobility, and behavioral status among other factors.