Medicaid Eligibility Program Client Referral Form Date: Facility Admin Name: Facility Name as it appears on Facility Permit: Facility Admin Email: d/b/a Summary/Notes: Account Information Resident's Name: Admit Date: Discharge Date: Discharge Location: Responsible Party Name: Address: Relationship/Phone: Amount Due to Date: Attachments Please attach the following documents along with any other pertinent information: Resident Face Sheet Most Recent MDS, BIMs, Physician Evaluation Admission Agreement, (signed & dated) (All pages) Copy of Power of Attorney, Guardianship/Conservatorship, Promissory Notes, etc. Signed Medicaid Authorized Representative Form(s) All Medicaid Applications, Medicaid Notices and Communications (including emails) All Verifications, Financial Information Worksheets, Resident Trust Account Statement Complete Payment Reconciliation or Billing History for all Payer Types Complete Billing Activity Notes/Collection Notes/Summary of Collection Efforts Other Attached Documents: All uploaded attachments must be PDF documents Submit Form Visit HBS Website