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Family and Social Services Administration

Medicaid Policy Home > Forms, Documents & Tools > Forms > Office of Medicaid Policy and Planning Office of Medicaid Policy and Planning

The following forms can be completed online and then printed

Certification by Physician for Long-Term Care Services and Physical Examination for PASARR Level II 45278
Completed by the physician. It is an attachment to the Form 450B (SF 38143 Physician Certification for Long-Term Care) to provide additional medical examination information on individuals with a mental illness or a developmental/intellectual disability. This form (along with the Form 450B) is used to determine the needs (level of care) of the individual for Medicaid reimbursement in a long-term care setting which may include a group home, intermediate care facility for the mentally ill/developmentally disabled, nursing facility or a home and community-based services waiver. NOTE: This form is also known as the Form 450B Section VI.

Determination of Disability - Consent for Release of Medical Information 44554
Given by the DFR caseworker to a Medicaid disability applicant so that the caseworker can obtain copies of the applicant's confidential medical records from his/her medical provider. Medical records are required in order to determine the medical eligibility for these applicants.

Hospice Authorization Notice for Dually-Eligible Medicare/Medicaid Nursing Facility Residents SF 51098

Hospice Provider Change Request Between Indiana Hospice Providers 48733
Completed when a member, or representative of the member, is not satisfied with his/her hospice provider. A member can change hospice providers during any benefit period. This change does not constitute a revocation of services.

Indiana Prescription Drug Plan for Seniors 49905

Medicaid Hospice Discharge 48734
Completed when a hospice provider discharges a member from future services as a result of (a) the member dies; (b) the member's prognosis is determined to be greater than six months; (c) the member safety or hospice staff safety is comprised.

Medicaid Hospice Plan of Care 48731
Must be completed by an interdisciplinary team member and must confer with at least one other member of the interdisciplinary team. One of the conferees must be a licensed physician or nurse, and all team members must review the plan of care. All of the services stipulated within the plan of care must be reasonable and necessary for palliation or management of the terminal illness and related condition. The plan of care must be signed by the hospice medical director and must also include two signatures from any of the other disciplines listed on the IHCP Hospice Plan of Care.

Medicaid Physician Certification 48736
Used in conjunction with the Hospice Election Form and the Hospice Plan of Care in requesting the first hospice benefit period. Assuming the information is sufficient and accurate, an initial benefit period of 90 days is approved. If benefit periods beyond the first 90 days are necessary, then recertification on the IHCP Physician Certification form and an updated Hospice Plan of Care is required for hospice authorization of the next benefit period.

Nursing Facility Level of Service - State Authorization and Data Entry 49120
Completed by the nursing facility where the individual resides. The purpose is to initiate or reinstate Medicaid reimbursement for nursing facility residents who have become Medicaid eligible and who have already been approved for nursing facility placement through the state and federal PAS/PASRR program. NOTE: This form is also known as the Form 450B SA/DE.

PASARR Categorical Determination for Short-Term Nursing Facility Care - Certification by Physician for Long-Term Care Services 45932
Completed by PAS Agency or Adult Protective Services. The purpose is to authorize a short-term admission into a nursing facility for a person with mental illness or developmental disability for respite care of up to 30 days or 7 days of Adult Protective Services placement. These individuals are exempt from the full PASRR Level II assessment during this short-term placement. NOTE: This is also know as Section V, Part B of the Form 450B.

Physician Certification for Long-Term Care Services 38143
Completed by the physician. The purpose is to obtain the medical information from the attending physician for the determination of medical needs for level of care for admission to and Medicaid reimbursement to nursing facilities, for Medicaid reimbursement for intermediate care facilities for the mentally ill or developmentally/intellectually disabled, for the Medicaid home and community-based services waiver programs and for the state-funded CHOICE program. It may be used by other programs under DDARS besides CHOICE, but those are not listed here. NOTE: This form is generally known as the form 450B.

QMRP Certification for ICF/MR Level of Care Waiver 51036

Request for Medicaid Expenditures 6533

Request for Hardship Exception – Transfer of Property State Form 54167

 

These forms cannot be filled in online. They may be printed out and filled in by hand.

Application for Undue Hardship Waiver 48259
Completed by the heirs of Medicaid recipients who claim they will incur a hardship if the state enforces its claim against the deceased Medicaid recipient's estate. The form is provided to the heirs upon request by the local DFR office. At the time the state makes a claim against the estate, the recipient's heirs receive a notice concerning the undue hardship provisions and how to apply for an undue hardship waiver.

Certification - Plan of Care for Inpatient Psychiatric Hospital Services / Determination of Medicaid Eligibility 44697
Used to provide a written certification of need for inpatient psychiatric admissions. Hospitals must submit this form to Medicaid's Medical Policy Contractor for every admission to a private psychiatric hospital. State-owned psychiatric facilities must submit this form to the Medicaid Medical Review Team (MMRT). The form is reviewed by either the Medicaid Policy Contractor or the MMRT to determine appropriateness of the inpatient stay.

Change in Status of Medicaid Hospice Patient 48732
Completed when there is an eligibility status change. For example, if the hospice patient becomes Medicare eligible, the hospice provider must complete the "Change in Status Form" to enroll the IHCP-only hospice member in the Medicare hospice benefit once that individual has become Medicare eligible.

Claim for Assessment - Preadmission Screening and Annual Resident Review (PASARR) 43878
Completed by Community Mental Health Centers or Diagnostic and Evaluation Teams. Used to claim reimbursement for initial or annual PASRR Level II assessments of persons identified as possibly having a mental illness or developmental disability who are requesting admission to or continued stay in a nursing facility.

Medicaid Hospice Election 48737
Used by the member who is electing the hospice benefit and is used to select a particular hospice provider. Election of the hospice benefit requires the member to waive: (a) other forms of health care treatment of the terminal illness for which hospice care was elected or for treatment of a condition related to the terminal illness; (b) services provided by another provider that are equivalent to the care provided by the elected hospice provider; (c) hospice services other than those provided by the elected hospice provider or its contractors.

Medicaid Hospice Revocation 48735
Completed when a member, or representative of the member, is not satisfied with his/her hospice care and wishes to revoke hospice services. This form includes a signed statement that the individual revokes the election of IHCP hospice services for the remaining days in the election period. Note: A member can elect to receive hospice care intermittently, rather than consecutively, over the three benefit periods and can therefore elect and revoke hospice coverage an unlimited number of times.