![]() ![]() ![]() I am paying $_ per month for my care from my own funds. ![]() I certify that the above statements are true and correct to the best of my knowledge and belief. Signature of facility administrator or care provider Section 5: Signatures (To be completed by the facility administrator/care provider and veteran/widow) We must have the monthly charge broken down into the following categories:īase Rate (includes room, meals, laundry, housekeeping): $ Provided or supervised by a licensed health professional (RN, LVN, LPN) mg11 statement structure mg11 continuation sheet mg11 witness statement college of policing mg6 form mg21 police form. Type text, add images, blackout confidential details, add comments, highlights and more. If the patient receives medical or nursing services, are the services Edit your mg11 form download word online. administering medication, physical or mental therapy, assisting with personal hygiene, dressing bathing etc.)ĭescribe the services you provide: _ (If the patient is receiving Medicaid, what amount does Medicaid take from the patient ) His/her own funds which is not reimbursed by one of the sources What monthly amount does the veteran or patient pay from What is the monthly amount covered by this source? Is part of the patient’s cost covered by Medicaid, Medicare, or insurance Has the patient applied for Medi-Cal (Medicaid) Will the patient need this care indefinitely Phone number of facility or care provider: _ĭate entered facility or in home care began Other Care Facility (Foster Home, Adult Day Care, Rest Home, Group Home, Assisted Living) Please Print.)Ĭheck the box which describes the patient’s care status: Section 1: General Information (To be completed by the facility administrator.
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