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Virginia Administrative Code
Title 12. Health
Agency 30. Department of Medical Assistance Services
Chapter 50. Amount, Duration, and Scope of Medical and Remedial Care Services
11/21/2024

FORMS (12VAC30-50).

Virginia Uniform Assessment Instrument, UAI, Virginia Long-Term Care Council (1994)

I.V. Therapy Implementation Form, DMAS-354 (eff. 6/1998)

Health Insurance Claim Form, Form HCFA-1500 (eff. 12/1990)

Certificate of Medical Necessity-Durable Medical Equipment and Supplies, DMAS-352 (rev. 7/2010)

Questionnaire to Assess an Applicant's Ability to Independently Manage Personal Attendant Services in the CD-PAS Waiver or DD Waiver, DMAS-95 Addendum (eff. 8/2000)

DD Waiver Enrollment Request, DMAS-453 (eff. 1/2001)

DD Waiver Consumer Service Plan, DMAS-456 (eff. 1/2001)

DD Medicaid Waiver -- Level of Functioning Survey -- Summary Sheet, DMAS-458 (eff. 1/2001)

Documentation of Recipient Choice between Institutional Care or Home and Community-Based Services (eff. 8/2000)

Comprehensive Outpatient Rehab Facility Participation Agreement (undated; filed 11/2015)

Rehabilitation Hospital Participation Agreement (undated; filed 11/2015)

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