Statutes, codes, and regulations
Virginia Administrative Code
Title 12 - HEALTHAgency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICESChapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES
Part VIII - Organ Transplant Services
Form - [Effective 4/5/2025] FORMS (12VAC30-50)

Va. Admin. Code tit. 12, agency 30, ch. 50, pt. VIII, form [Effective 4/5/2025] FORMS (12VAC30-50)

Download
PDF
Current through Register Vol. 41, No. 9, December 16, 2024
Form - [Effective 4/5/2025] FORMS (12VAC30-50)

Virginia Uniform Assessment Instrument, UAI, Virginia Long-Term Care Council (1994)

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. 8/2000)

DD Waiver Enrollment Request, DMAS-453 (eff. 1/2001)

DD Waiver Consumer Service Plan, DMAS-456 (eff. 1/2001)

DD Medicaid Waiver -- Level of Functioning Survey -- Summary Sheet, DMAS-458 (eff. 1/2001)

Documentation of Recipient Choice between Institutional Care or Home and Community-Based Services (eff. 8/2000)

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

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

Va. Admin. Code tit. 12, agency 30, ch. 50, pt. VIII, form [Effective 4/5/2025] FORMS (12VAC30-50)

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.