Form MA-51 Medical Evaluation - Pennsylvania

Form MA-51 Instructions

Form-51 instructions are as follows:

1. Indicate the Medical Assistance (MA) recipient number, name of the patient, their social security number, date of birth, age, and sex.
2. State the name and license number of the attending physician.
3. Write down the place of the evaluation.
4. Obtain the signature of the patient to show their authorization to release their medical information.
5. Enter the physical characteristics and vital signs of the patient.
6. State whether they can leave the building in case of an emergency and whether they can take their own medications.
7. List diagnostic codes of diagnoses you have made.
8. Check the boxes to choose the types of care and therapy required.
9. Write down the orders that correspond to the needs you have listed above.
10. Check the boxes to indicate your opinion regarding the prognosis and rehabilitation potential of the individual in question.
11. State what kind of facility you recommend for the patient and whether they will be able to be discharged within a specific period of time.
12. Write down your name and telephone number. Sign and date the form.
13. Describe activities of daily living - you need to circle items that apply.
14. If the patient has any fractures or surgeries recently, write them down.
15. Record your name, add your contact information, sign and date the form.

Once the physician has completed the evaluation, this statement will be reviewed by the Medicaid agency and their designees to confirm the person is medically eligible and to indicate their length of stay in a medical facility. Then, the evaluation, signed by the licensed physician and reviewer, can be submitted to the facility that will provide medical care and services to the patient. Note that it will be valid only as long as the patient's conditions are reflected correctly.