Adm. date - Physician's order
Case Management Y/N?
Assessment/reassessment Y/N?
Assessment Date/MAP 351 A completed
Reassessment Date/MAP 351 A completed
Level of care dates
Confirmation notice date
Date Packet mailed or faxed to Pro
PA issue date & LOC dates
PA service dates
Previous PA dates
PA units approved (Adult day)
PA units approved (Case Mgt.)
PA units approved (Therapies)
Date of DSI Application
QMB (Y/N)?
Prior Medicaid Y/N?
      If no, MAP 4200 service date
Liability Amount/ACH or Bill to
Liability amount Outstanding
Issue & effective date MAP 552
PVA Office Contacted (Y/N)?
Personal Vehicle (Y/N)?
Grant Type (CVADD/KRADD)?
Total dollar amount denied: