Form - [Effective until 4/5/2025] FORMS (12VAC30-50)

Virginia Uniform Assessment Instrument, UAI, Virginia Long-Term Care Council (rev. 11/2018)

I.V. Therapy Implementation Form, DMAS-354 (eff. 6/1998)

Health Insurance Claim Form, Form HCFA-1500 (eff. 12/1990)

Certificate of Medical Necessity-Durable Medical Equipment and Supplies, DMAS-352 (rev. 7/2010)

Questionnaire to Assess an Applicant's Ability to Independently Manage Personal Attendant Services in the CD-PAS Waiver or DD Waiver, DMAS-95 Addendum (eff. 8/2005)

Comprehensive Outpatient Rehab Facility Participation Agreement (undated; filed 11/2015)

Rehabilitation Hospital Participation Agreement (undated; filed 11/2015)

Medical Necessity Assessment and Private Duty Nursing Service Authorization Form (DMAS 62)

Notes

Amended, Virginia Register Volume 32, Issue 06, eff. 1/1/2016; Amended, Virginia Register Volume 40, Issue 5, eff. 10/6/2023, exp. 4/5/2025 (Emergency).

Statutory Authority: § 32.1-325 of the Code of Virginia, 42 USC § 1396 et seq.