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To order a Medicaid service through the Division of Adult Services and Aging, whether it be Personal Care or the Home and Community Based Waiver, a person's primary physician is asked to complete the physician report/order form. An individual can only be eligible for one of the programs. This form requires minimal information regarding the eligible individual.
In addition, a person's primary physician is also asked to complete this form with the required medical information needed to make a level of care determination when the state's Medical Assistance Program is being requested as a payment source. A recent Medical History and Physical or Discharge Summary may be provided in addition to the form.