Regional Forms U.S. States Templates Georgia FormsFillable DMA 6, Physicians Recommendation Concerning Nursing Facility Care

What Is DMA 6 Form?

Also known as Physicians Recommendation Concerning Nursing Facility Care, it’s a document that provides a physician’s confirmation of a person’s need for nursing facility care.

What the DMA 6 form is used for

The sheet is used for:

verifying that the patient in question needs nursing home care.

Sections of the DMA-6 form

Section A, Identifying Information: the applicant's name and address, Medicaid number, birthdate, and where the patient is transferring from (item 9, check one).
Section B, Physician's Report and Recommendation: the treatment plan (a copy of the order sheet may be attached if more convenient), medications with name, dosage, route and frequency, the recommendation regarding the level of care considered necessary, and the physician's signature.
Section C, Evaluation of Nursing Care Needed: check the appropriate boxes and complete the other entries in that section.

Do not write below the line marked "DO NOT WRITE BELOW THIS LINE".