Georgia Medicaid uses this one-page form to establish that a person needs nursing facility or intermediate care for the intellectually disabled (ICF/ID) level of care. The attending physician records admission diagnoses with ICD-10 codes, the treatment plan, medications, the recommended level of care and how long care is needed, then certifies the need. The facility submits it with its level-of-care request.
Section A identifies the applicant and facility, and the patient, spouse, parent, other relative or legal representative signs the release in item 10. The attending physician completes Section B and signs the certification in item 18; Section C records nursing care needs and is signed in item 34.
Enter the applicant's name, address and county, Medicaid number, Social Security number, sex, age and birthdate. Check one facility type (nursing facility or ICF/ID) and one type of recommendation (nursing facility, ICF/ID or continued placement). Add the patient's name, nursing facility admission date, where the patient is transferring from (hospital, home, another nursing home, private pay or Medicare), home address and phone, and the date of the Medicaid application.
Item 9A records the Level I/II mental health and intellectual disability screening with its restricted authorization code and date. Item 9B, with its own code and date, confirms the stay is not a re-admission for OBRA purposes. Items 10 and 11 are the signature and date of the patient, spouse, parent, other relative or legal representative authorizing release of medical data.
List the primary, secondary and other diagnoses on admission to the facility with ICD-10 codes in items 12 and 12A; the hospital transfer report may be attached. Item 13 is the treatment plan, where an order sheet can be attached instead, plus the hospital dates and the primary, secondary and other hospital diagnoses.
The medication grid asks for each drug's name, dosage, route and frequency. The adjacent column, also numbered 16, lists diagnostic and treatment procedures by type and frequency. Both sit in Section B, between the treatment plan in item 13 and the level of care recommendation in item 14, and form part of the physician's report.
Item 14 recommends skilled, intermediate or ICF/ID care. Item 15 gives the length of time care is needed, permanent or temporary with estimated months. Item 16 asks whether the patient is free of communicable diseases, and item 17 whether the condition could be managed through community care or home health. Item 18 is the physician's certification and signature, followed by printed name, address, date signed, license number and phone.
Check boxes for diet (regular, diabetic, formula, low sodium, tube feeding), bowel and bladder continence, overall condition, restorative potential, and mental and behavioral status. Record decubitus status, hours out of bed per day and care items such as catheter care, IV, sterile dressing or suctioning. Item 30 shows therapy frequency per week, received and needed, for physical, occupational, speech and other therapies.
Rate impairments of sight, hearing, speech, limited motion and paralysis from severe to none, and activities of daily living (eating, wheelchair, transfer, bathing, ambulation, dressing) from dependent to not applicable. Add remarks in item 32, the pre-admission certification number in item 33, and the signature and date in items 34 and 35.
This block belongs to the review contractor, printed on the form as GMCF. It records the continued stay review date, payment date, number of days approved, level of care recommended, length of stay, the reviewer's signature and date, and whether attachments were received. Leave it blank.
Download the current version from the source each time; forms change without notice.
Physician's Recommendation Concerning Nursing Facility Care or Intermediate Care for the Intellectually Disabled
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The attending physician signs the certification in item 18 and adds printed name, address, date signed, license number and phone in items 19 to 21. The patient, spouse, parent, other relative or legal representative signs item 10, authorizing release of medical data to DCH and the Division of Family and Children Services.
DMA-6 is the physician's recommendation concerning nursing facility care or intermediate care for the intellectually disabled. Georgia lists DMA-6A separately as the Physician Recommendation for Pediatric Care. Use the version that matches the patient and the type of placement the facility is requesting.
Items 12 and 12A list primary, secondary and other diagnoses on admission to the facility, each with an ICD-10 code box, and a hospital transfer report may be attached. Item 13 also asks for hospital dates and the primary, secondary and other hospital diagnoses alongside the treatment plan.
Yes. Item 6 includes Continued Placement as a type of recommendation alongside nursing facility and ICF/ID, and the reviewer block records a continued stay review date. Item 15 asks whether care is needed permanently or temporarily, with an estimated number of months for a temporary stay.