Form DCF-MA1 "Medical Assistance Form" - Connecticut

What Is Form DCF-MA1?

This is a legal form that was released by the Connecticut State Department of Children and Families - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 5, 2014;
  • The latest edition provided by the Connecticut State Department of Children and Families;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DCF-MA1 by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Children and Families.

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Download Form DCF-MA1 "Medical Assistance Form" - Connecticut

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DCF-MA1
State of Connecticut
DSS Routing Information
Replaces DCF-W1Y & DCF-M2T
Department of Children and Families
(DSS-M2T)
DO: ____________________________
Revenue Enhancement Division
09/2014 (Rev.)
Medical Assistance Unit
EW: ____________________________
MEDICAL ASSISTANCE FORM
Date:
9/5/2014
LINK Case ID:
LINK INFORMATION
LINK Person ID:
Last Name:
First Name:
MI:
CHILD’S
DOB:
INFORMATION
Sex:
Race:
SS#:
Medicaid ID#:
Date Child Placed with Caregiver (below):
Caregiver’s Name:
Street Address:
PLACEMENT
City:
INFORMATION
State:
Zip:
Telephone:
Caregiver’s Relationship to Child:
Last Name:
DCF SOCIAL WORKER
First Name:
INFORMATION
Telephone:
AREP CODE TYPE – “R3”
DCF Office Address:
CHILD’S DCF LEGAL STATUS:
Child’s Current Legal Status with DCF:
Is the child a US citizen or an alien who is
CITIZENSHIP STATUS:
currently registered with USCIS and legally
authorized to be in the United States?
Policy Holder:
Policy Holder’s DOB:
CHILD”S
COMMERCIAL
Policy Number:
Policy Holder’s SS#:
INSURANCE
Ins. Company Name:
Type of Insurance:
INFORMATION
Effective Dates:
From:
To:
DCF CASE CLOSURE
Date DCF Case Closed:
REMARKS
Processing directions upon completion of this form (follow the directions EXACTLY as outlined below):
1)
Make sure that all of the information is complete –
telephone numbers must contain area codes; addresses must contain zip codes.
2)
Click on File
3)
Click on Send To (You may have to click on the double down arrows at the bottom of the drop down box to display this option.)
4)
Click on Mail Recipient (as Attachment)… (You must select “as Attachment” or the form will not be transmitted properly.)
5)
Click on the To… button
6)
Select “DCF Medical Assistance” from the list; click on the To
button; click on OK
7)
Enter the child’s name in the Subject line
8)
Click on Send (A copy of the e-mail with an attachment of this form will appear in your Sent Items folder.)
9)
Close the document. When asked if you want to save the changes, click No.
DCF-MA1
State of Connecticut
DSS Routing Information
Replaces DCF-W1Y & DCF-M2T
Department of Children and Families
(DSS-M2T)
DO: ____________________________
Revenue Enhancement Division
09/2014 (Rev.)
Medical Assistance Unit
EW: ____________________________
MEDICAL ASSISTANCE FORM
Date:
9/5/2014
LINK Case ID:
LINK INFORMATION
LINK Person ID:
Last Name:
First Name:
MI:
CHILD’S
DOB:
INFORMATION
Sex:
Race:
SS#:
Medicaid ID#:
Date Child Placed with Caregiver (below):
Caregiver’s Name:
Street Address:
PLACEMENT
City:
INFORMATION
State:
Zip:
Telephone:
Caregiver’s Relationship to Child:
Last Name:
DCF SOCIAL WORKER
First Name:
INFORMATION
Telephone:
AREP CODE TYPE – “R3”
DCF Office Address:
CHILD’S DCF LEGAL STATUS:
Child’s Current Legal Status with DCF:
Is the child a US citizen or an alien who is
CITIZENSHIP STATUS:
currently registered with USCIS and legally
authorized to be in the United States?
Policy Holder:
Policy Holder’s DOB:
CHILD”S
COMMERCIAL
Policy Number:
Policy Holder’s SS#:
INSURANCE
Ins. Company Name:
Type of Insurance:
INFORMATION
Effective Dates:
From:
To:
DCF CASE CLOSURE
Date DCF Case Closed:
REMARKS
Processing directions upon completion of this form (follow the directions EXACTLY as outlined below):
1)
Make sure that all of the information is complete –
telephone numbers must contain area codes; addresses must contain zip codes.
2)
Click on File
3)
Click on Send To (You may have to click on the double down arrows at the bottom of the drop down box to display this option.)
4)
Click on Mail Recipient (as Attachment)… (You must select “as Attachment” or the form will not be transmitted properly.)
5)
Click on the To… button
6)
Select “DCF Medical Assistance” from the list; click on the To
button; click on OK
7)
Enter the child’s name in the Subject line
8)
Click on Send (A copy of the e-mail with an attachment of this form will appear in your Sent Items folder.)
9)
Close the document. When asked if you want to save the changes, click No.