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Applications & Forms
For Beneficiaries
- Application for the SC-Medicaid Program - English
FM 910- Last Updated: 09/07
- Application for Partners for Health (Medicaid) - Spanish
FM 910-S- Last Updated: 03/07
- Application for Partners for the SC Medicaid Program - English
Specifically for Families, Pregnant women + Children. FM 505- Last Updated: 04/08
- Application for Partners for the SC Medicaid Program - Spanish
Specifically for Families, Pregnant women + Children. FM 505- Last Updated: 04/08
- Disability Report-Adult
FM 3218 ME- Last Updated: 12/06
(if under age 65, use with 910 & 910-S)
- Application for TEFRA (Katie Beckett)- English
FM 3290 ME- Last Updated: 04/07
(use with 3218-D ME, 3291 ME & FM 921)
- Disability Report-Child Under Age 19
FM 3218-D ME- Last Updated: 09/07
(use with 3290 ME, 3291 ME & FM 921)
- In-Home Care Certification
FM 3291 ME- Last Updated: 10/04
(use with 3290 ME, 3218-D ME & FM 921)
- Authorization to Disclose Health Information
FM 921 - Last Updated: 11/07
(use with 3290 ME, 3291 ME & 3218-D ME)
- Application for Nursing Home, Waiver Services, General Hospital - English
FM 1296 ME- Last Updated: 07/06
- Application for Nursing Home, Waiver Services, General Hospital - Spanish
FM 1296-SPA ME- Last Updated: 05/02
- Application for Specified Low Income Medicare Beneficiaries (SLMB)
FM 914 - Last Updated: 08/06
- Application for Family Planning - English
FM 400- Last Updated: 04/08
- Application for Medically Indigent Assistance Program (MIAP)
FM 207- Last Updated: 09/07
- Application for Breast and Cervical Cancer Program - English
FM 913 - Last Updated 09/07
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Civil Rights Discrimination Complaint
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If you have questions about this form, call SCDHHS at (803)898-2605. Return the completed form to:
Office for Civil Rights, SCDHHS, PO. Box 8206, Columbia, SC 29202-8206
Privacy Complaint Form
- Health Information Privacy Complaint. If you have questions about this form, call SCDHHS OCR at (803) 898-2605. Return the completed form to:
Office for Civil Rights, SCDHHS, P.O. Box 8206, Columbia, SC 29202-8206
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Health Care Power of Attorney
- Description: Information about and form for Health Care Power of Attorney- see section 62-5-504.
Posted: 1/15/2008 4:04:46 PM
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Living Will
- Description: Form for Declaration of Desire for a Natural Death.
Posted: 4/10/2003 12:04:45 PM
- Disclaimer:
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These forms are statutory and may not meet your particular needs. Before you complete and sign these forms, you should consult with an attorney to determine if some other document would better meet your needs.
For Providers
Medicare & Health Insurance Carrier Code Lists
Hurricane Katrina Uncompensated Care Pool (UCCP)
Request Form for Reimbursement of Uncompensated Care
Some documents require other software
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