Attention New and Existing Patients:
For new submitted applications and renewals, the $50 fee is non-refundable..
Photo:
A hospice patient must provide either 1. A clear, color photo of the patient’s face taken within the last six months to reflect the patient’s current appearance or 2. A letter from the attending hospice provider (Attending of Hospice Record or AOHR) on hospice letterhead stating that the patient is under his or her care.
REQUIRED: AOHR Letter
A letter must submitted from the Attending of Hospice Record provider on hospice letterhead stating that the patient is a hospice patient under his or her care. The file can be uploaded in .jpg or .pdf format.
Maryland Address
PLEASE NOTE:
REQUIRED:
1.Maryland Medicaid ID Number This is the ID number found on your State of Maryland Medicaid Program (Red) ID card. 2.Maryland Medicaid ID Card Upload an electronic copy of your State of Maryland Medicaid Program (Red) ID card. 3.Proof of Current Maryland Medicaid Enrollment Acceptable proof of current Maryland Medicaid Enrollment includes: 1) A Certificate of Creditable Coverage,OR 2) An Eligibility Determination Letter from the Maryland Health Connection.
Note:If you have lost the card and need a replacement or need a Certificate of Creditable Coverage or Eligibility Determination Letter, please contact Maryland Medicaid Beneficiary Services at 1-800-492-5231, or the Maryland Health Connection at 1-855-642-8572 (TTY: 1-855-642-8573). Please be sure the document is legible. Must be a PDF or an image file (.jpg, .png, or .gif) no larger than 3MB.
If you are currently enrolled in the Veterans Affairs of Maryland Health Care System you must provide a copy of your VA health insurance card.
A hospice patient must provide a letter from the Attending of Hospice Record provider on hospice letterhead, stating that the patient is a hospice patient under his or her care. The file can be uploaded in .jpg or .pdf format.