KATIE BECKETT PHYSICIAN FORMS

You've researched and gathered information about the Katie Beckett medicaid waiver in GA and you are ready to take the plunge into filling out the forms. The first set of forms to focus on getting rolling are the physician forms, because you have to wait on the doctor(s) to draft, review, and sign them. For this page, I'll provide detailed information on how each item should be filled out and/or drafted. Click the links in the below list to scroll directly to that section on this page. For a current copy of the physician forms, visit the Georgia Medicaid website and download the pdfs under the 'Forms' subheading.

Here are the forms to work on for being filled out by a physician. Click on each one to scroll to the section with step-by-step instructions on how to fill it out.

Blank Forms from GA Medicaid Site

Click through to download your blank starting forms from the GA TEFRA Katie Beckett Medicaid website.

If you're filling out a draft of these forms to help your physician get started, follow these directions closely and double-check what you've put in. I would recommend using the 'Fill & Sign' mode in the free version of Adobe Acrobat Reader to complete this on your computer. Then you can save an electronic copy and make quick edits without having to fill out the entire form again if there is a mistake.

If your physician feels comfortable filling out these forms themselves, review what they have given you with the details below and make sure there are no mistakes. If you find mistakes, you can either suggest edits to them or create a fresh version incorporating the corrections so that they can just review and sign. For me, I emailed draft/example versions of these to the physician and asked them to review and send me any corrections. Once the document was finalized, the physician signed them (leaving the date blank) and I picked up the originals. If they date the forms you'll have to request a second copy without the dates filled in.

In my case, my daughter's neurologist had a social worker who had a lot of personal experience with Katie Beckett and offered to complete these forms for me. When I got them back, they had multiple errors that would have resulted in a denial, so I ended up making corrections on a fresh version and having the doctor just review & sign.

Obviously there is a bit of back & forth required for these forms, which is why I recommend you get things going pretty early in the overall application process.

Disclaimers

I am not an attorney, medical professional, or professional advocate. I'm just a mom who has been through it and would like to help others have a smoother experience than I had. 🙂 I'm hopeful that these resources will be helpful to you and I will do my best to keep them updated and relevant, but please note that following my advice is no guarantee of approval. Also, please note that I live in Georgia, and Medicaid applications are state-specific. If you live in another state, find resources specific to your state to use as a guide.

Physician's Recommendation Pediatric Care Form (DMA6)

For items 9, 11, and 27 below, make sure they understand to leave the dates blank. I covered those spaces with a small post-it note for my physician and wrote on it 'please leave blank', even after explaining to them that the date needed to be left blank for now. Filling in a date box is just such an automatic thing for all of us, and it's a point of frustration to have to ask for a new signed form multiple times just because they wrote in the date on autopilot. So try to make that very clear and give a foolproof way for them to remember to leave the dates blank as they are signing this one in particular since there are three date boxes (ugh).

This form can be filled out by your pediatrician, neurologist, cardiologist, developmental pediatrician, or another doctor who has an authoritative knowledge of your child's condition(s). This cannot be completed by a therapist. It has to be an MD.

To download the blank form from state of GA Medicaid Department, click here. To view an example form I've filled out with dummy info as a guide ONLY, click here.

Detailed instructions for filling this form out are below. Take a deep breath; this one is a bit complicated and will take some time. This is the hardest of them, though, so once you have this out of your way, the rest are a bit easier.

DMA-6 Page 1

  1. For Applicant's Name and address, enter your child's first name, county of residence, and mailing address.
  2. For Medicaid Number, if this is a new application, put 'New application' in this field. If you are submitting a renewal, put in your child's Medicaid ID Number.
  3. Enter your child's Social Security Number.
  4. Enter your child's sex, current age, and birthdate.
  5. Enter the name, practice name, city and state of your child's pediatrician.
  6. Enter a phone number where you can be reached on your child's behalf. For me, I put in my personal cellphone for this field.
  7. For the institutionalization question, check the 'yes' box.*
  8. Indicate whether your child attends school.
  9. Leave this blank for now; this date MUST be consistent across your application, so you don't want to fill it out until you are actually ready to mail it.
    List the names of the child's caregivers (in most cases, the names of the two parents / legal guardians).
  10. Leave this blank for now; you will sign and date this when you are ready to mail it.
  11. Again, the date MUST be consistent across your application, so definitely leave the date blank for now.
  12. For most children applying for Katie Beckett, this will require more information than this space permits. You can put 'see attachment' in the box and then include a separate attachment page with a 1-2 paragraph summary of your child's history. Remember, this form is being filled out for the physician to sign, so keep in mind you are sharing your child's history from the physician's perspective. At the top of your attachment page, put your child's full name and date of birth in case the page becomes separated from your child's application as it is being reviewed by Medicaid. This attachment page may also be used for additional items below. (Here is an example.)
  13. For the diagnosis section, you will need to refer to notes from recent doctor visits and/or your doctor's input if you don't have the diagnoses and codes handy. For most folks filling out this application, you likely have more than three diagnoses, so your attachment page (from item 12) will come in handy again. The #1 diagnosis should be the strongest or most severe diagnosis for your child. It may be 'Chromosomal Abnormality' for a genetic disorder, or another diagnosis for a pervasive condition. Enter the corresponding ICD diagnosis code in the space that is labeled '1. ICD.' The #2 diagnosis code should be the next most significant diagnosis for your child, with the corresponding ICD diagnosis code listed in the #2 ICD space. If you need to list more than three diagnoses, for #3 put 'See attachment.' On the attachment form, list all of the diagnoses (including the first two) in order with the most significant/severe diagnoses listed first.
  14. List all of your child's medications. Use the attachment page if this section is not big enough for the list for your child. List what will fit here, and on the last line type 'See attached.' Then, on the attachment page, include the complete list so that the Medicaid reviewer can see them all in one place.
  15. List all of your child's diagnostic and treatment procedures.  Use the attachment page if this section is not big enough for the list for your child. List what will fit here, and on the last line type 'See attached.' Then, on the attachment page, include the complete list so that the Medicaid reviewer can see them all in one place.
  16. List your child's previous hospitalizations, rehabilitative services, other health services, and hospital diagnoses if applicable. As indicated on the form, use your attachment page to provide details if they will not fit on the form. If your child does not require daily medical attention but requires a frequency of 5 or more therapies per week, that plan would fall under the 'Rehabilitative/Habilitative Services' category. You would put 'See Attachment' in this blank, then write a summary of the therapy recommendations for your child on the attachment page.
  17. Enter any anticipated dates of hospitalization, or put 'N/A' if this does not apply to your child.
  18. For Level of Care recommended, most folks will check the 'ICF/ID Facility' box. This indicates an intermediate level of care as opposed to the full care of a 'Nursing Facility.' Remember that this form is to be reviewed and signed by a physician, so what they are communicating on this item is what level of care would be needed if the child was to be institutionalized. The goal with Katie Beckett is that the same level of care be provided to the child outside of the institutional setting, so that is why they are indicating here what level of institutional care should be replicated for your child. One of these boxes must be checked in order for your application to be considered.
  19. Check the appropriate box for the Type of Recommendation. If you are applying for the first time, check 'Initial.' If you are applying for a change in the level of care, check that box. If you are applying for a renewal with the same level of care, check 'Continued Placement.'
  20. Check the appropriate box for your child. 'Hospital' would indicate they are leaving a full-time hospital setting to be cared for at home. 'Private Pay' would indicate that you have been paying privately for their care in an institutional setting. Most folks would check 'Lives at home' to indicate they have been cared for at home previously.
  21. Enter the appropriate length of time the care will be needed for your child. If your child is recovering from an injury or temporary illness, indicate the recommended / expected length of the recovery time where they will need a high level of care. Since this form is representing the physician's recommendation, consult your physician or recent doctor visit notes to make sure you are entering their recommendation accurately.
  22. Enter in this box whether or not your child has a communicable disease.
  23. Check whether your child's condition could be managed by Community Care (therapists, doctors, etc. in your area) or Home Health Services (nurses and therapists coming into your home). You can check both boxes if both are applicable.
  24. Enter the Physician's Name and address who is signing this form.
  25. This is where the physician will sign.
  26. Again, leave the date blank until you are ready to mail this off. Your application will automatically be denied on a technicality if these dates don't match, so although I'm starting to sound like a broken record, it is highly important that your physician NOT date this when they sign it.
  27. Enter the license number of the physician who will be signing the form. You can obtain this number by searching online or calling the physician's office.
  28. Enter the phone number of the physician filling out this form.
  • On your attachment page, add a spot for your physician to sign. Include a spot for the date but remind them to leave it blank.
  • At the top of the DMA6 page 1, Select the box for 'TEFRA/Katie Beckett.'
  • Here is an example of an attachment page.

*Some additional notes on Item 7. Indicating that your child requires institutionalization is a difficult thing for a lot of parents, including me. Many parents would go to great lengths to provide for their child instead of placing them in an institution, so sometimes it's hard to check this box. If you don't check 'yes' on Item 7, however, your Medicaid application will be denied. The premise of the Katie Beckett waiver is that it is more cost effective to provide services for the child in their home environment rather than paying for institutional care. One suggestion is to check the 'yes' box for Item 7, and then type/write in the space 'as a last resort.' This indicates that you (the parent) agree that an institutional-level of care (meaning 5+ therapies per week) is needed for your child, but that you would only place them in an institution if you had no other alternative. Adding 'as a last resort' to this box may increase your comfort level in checking 'yes' for Item 7.

DMA-6 Page 2

  1. Check any nutritional challenges applicable to your child. Use the space at the bottom to list any additional comments.
  2. Check any bowel challenges applicable to your child. Use the space at the bottom to list any additional comments. If they are too young to be toilet trained, check 'Age Dependent Incontinence.'
  3. Check any cardiopulmonary challenges applicable to your child. Use the space at the bottom to list any additional comments. If they have no breathing or heart challenges, check 'Room Air.'
  4. Check any mobility challenges applicable to your child. Use the space at the bottom to list any additional comments.
  5. Check any behavioral challenges applicable to your child. Use the space at the bottom to list any additional comments.
  6. Check any skin-related challenges applicable to your child. Use the space at the bottom to list any additional comments.
  7. Check any urogenital challenges applicable to your child. Use the space at the bottom to list any additional comments. If they are too young to be toilet trained, type 'Age Dependent Incontinence.'
  8. Indicate the number of surgeries your child has undergone.
  9. Indicate the number of therapies currently happening for your child.
  10. Indicate the neurological status for your child. Use the space at the bottom for any additional notes.
  11. Indicate the number of days per week therapies are currently happening for your child.
  12. For 'Remarks', you'll want to indicate that a full Psychological Evaluation is included and make sure the Psych Eval follows this page in your final application packet.
  13. Indicate your child's pre-admission certification number if they are going to be hospitalized. If not applicable, just type 'N/A.'
  14. Leave the date signed BLANK.
  15. Fill in the name of the physician and have them sign here.

If you are filling out these forms on your physician's behalf, print them out so that you can label with post-its where to sign, and use different post-its to cover up the date areas so that they will NOT mark the date. Remember, inconsistent dates will result in a technical denial, so this is not to be ignored. You will put all dates in once you have it ready to mail. Once you get the signed forms from your physician, use post-its to make notes for yourself for the spots where you do need to put the date so that you don't miss any.

Level of Care Statement (DMA-706)

This form should be completed by the same physician (MD) as completes the DMA-6 above.
Blank form from state of GA Medicaid Department: link.

To view a completed example, click here.

Similar to the DMA-6, you may want to complete this form for them so that they can just sign it; if they feel comfortable filling it out, check over it once they give it to you and make sure it's consistent with the guidelines below. In particular, be careful about item 3: the 'Recommended Level of Care.'

  1. Personal information: Fill in the child's full name, date of birth (MM-DD-YYYY format) and Social Security number.
  2. Diagnosis: In this section, you'll list the diagnoses applicable to your child, with the highest level of need first. Hint: do not list autism as their first diagnosis. Remember that autism alone does not allow you to qualify for Katie Beckett. You'll need something more medically specific, communicating a more unique level of need, in the first spot on the list here.
  3. Recommended Level of Care: This one can get you denied if not properly filled out, so be super careful here: one of these boxes MUST be checked in order to be considered for Katie Beckett. Your physician will not know what these mean unless they've filled out this application many times. The first option, 'Nursing facility level of care,' would be checked if your child needs 24-hour nursing care. This is likely applicable if they are on a feeding tube, breathing support, etc. The second option, 'Immediate Care Facility,' is applicable if your child needs significant levels of support but not 24-hour nursing care. The Katie Beckett team defines this as 5 or more therapies per week. Essentially, if your kid needs what would average to daily therapies or interventions in a medical facility (like a therapy clinic), this is the one you would check. Remember: the goal of the Katie Beckett program is to save overall healthcare costs by allowing children to be cared for at home instead of having to have institutional support. This area indicates which level of institutional support would be required if your child didn't have appropriate support for care in the home. For most folks, including me, the second box (Immediate Care Facility) would be checked: my child does not require 24-hour nursing care, but does require daily intervention.
  4. Medical History: In these two lines, a very short summary of the condition and presentation should be provided. You can include an attachment here as well, particularly if you have hospital discharge papers.
  5. Current Needs: Check the line for any categories that do not apply. For categories that do apply, a short description of professional needs should be listed.
  6. Therapy: The frequency of therapies should be listed here in number per week. Please note that there should be at least 5 total therapies per week recommended here if you are checking the 'Interediate Care Facility' box in #3 above. Otherwise, you will be denied.
  7. Hospitalizations: Patient's recent hospitalizations should be listed in this area.
  8. School: Indicate in this area whether the child is in school or not, and if so, how many hours per day, and days per week. If the child is not in school, check 'N/A.' If the child has an IEP (Individualized Education Plan) through public school OR an IFSP (Individualized Family Service Plan) through Babies Can't Wait, check the line. If they have in-school nursing care, indicate that as well or check 'N/A.' If the child has in-school nursing care, attach the most recent month's notes from the nurse who services them, which is available upon request from the school.
  9. Skilled nursing hours: Indicate how many hours per day the child receives skilled nursing care (which is NOT the same as therapies).
  10. Signatures & Dates: The physician helping you with this would sign here. You will sign below. The dates should be left blank until you are ready to mail it all in. ALL DATES MUST MATCH or you will get a technical denial, so wait and date everything as you are putting it all into your mailing envelope at the end. For your physician signing this, put a post-it over the date box and write 'please leave date blank.'

Cost Effectiveness Form (DMA-704)

Again, this form should be completed by the same physician as the other forms above. For this form in particular, there is no way the physician can complete this form without input from you. Specifically, they will need information on the cost of your care needs from your medical billing history.

To download the form from the GA Medicaid website, click here.

To view a completed example for reference, click here.

  1. Patient information: Enter the child's full name. For Medicaid#, if this is your first application, enter 'New application.' Again on the Diagnosis line, list them with the most severe/specific diagnosis first, continuing down the line from there. For 'Prognosis,' they are looking for their money to be well-spent and effective, so you want to indicate that the benefits you'll receive from the Katie Beckett program will provide positive improvement. In our case, because her diagnosis of a genetic disorder is permanent, I listed 'Permanent, but good with intensive therapeutic support.' Your physician may have input on what they'd like to put here.
  2. For the monthly costs, you'll need to do some digging into old medical bills and insurance reports. For each category, you list the approximate monthly cost that Medicaid could be on the hook for covering. The Katie Beckett staff literally plugs this number into their system to see if providing you with support will be cost-effective for them (thus the title of this form), so don't over- or under-estimate. Be as accurate as you can. Total the amounts in the 'Total' line. Double-check your math.
  3. Will home care be as good or better than institutional care? - The 'Yes' box MUST be checked for your Katie Beckett Medicaid application to be considered. Remember, the entire goal of the Katie Beckett program is for kids to receive care in the home as opposed to in an institution. If your physician indicates 'No' here, you are not an appropriate candidate for Katie Beckett, so your application will be denied.
  4. Signature & Date: Once again, have your physician sign here, but they should NOT date it. Place your post it to help prevent them dating it accidentally!

Prescription Order of Medical Necessity

This item does not have a form to complete; it's a statement from your child's pediatrician indicating the overall treatment plan they are prescribing for your child. It does not have to be the same provider as the one who filled out the other three Physician Forms listed above. In my case, our pediatrician helped me with this form but our neurologist helped with the other physician forms. If your pediatrician has created this type of form before, they may have a template for making it for you. In my case, this was all very new for our pediatrician. I created a draft version in GoogleDocs, emailed it to the pediatrician in advance, and discussed it with them during an office visit. We made some tweaks, they printed it, and signed it while I was there. Obviously your doctor may prefer a different approach, but the goal is to get this form completed and signed with a clear picture of what the pediatrician is prescribing as a treatment plan for your child.

To view an example for reference, click here.

For this document, I recommend the following order:

  1. Physician's office title, address, and phone number
  2. The reference line 'Patient Prescription'
  3. Patient reference information: full name, date of birth, address, and gender
  4. Patient diagnosis: List 1-3 of your child's most severe / overarching diagnoses here.
  5. Diagnostic codes: Here, list the same codes you pulled together for the DMA-6 above; specifically, list the codes in the order of most severe first.
  6. A statement indicating that the doctor is prescribing the following treatments as medically necessary.
  7. A list of all treatments the pediatrician is prescribing for your child, including medications, therapies, etc. This should include specifics that would be on a normal prescription - dosage for medications, time and frequency for therapies, etc.
  8. A place for the pediatrician to sign and date. As long as the date here is within striking distance of the rest of your application, this one is okay. No need to wait to do the date at the end.

That's a wrap for Physician Forms!

You made it through the physician forms list! Take a moment to recognize that it's a serious accomplishment to even read through these instructions. They're quite an undertaking. As I mentioned in the introduction section, there may be quite a bit of back and forth with your doctor on finalizing these forms. They are confusing, and most of us have zero experience with them. Start on these forms early in your application process and just know that it is going to take multiple emails, phone calls, office visits, and a good bit of time to get these wrapped up and ready to go.

Once you have your Physician Forms in process, start working on your Personal Forms. The Personal Forms are MUCH easier than the Physician Forms, so you are on the home stretch! My goal in writing this guide is to have a clear, accurate, step-by-step process that makes your life a bit easier. Have a question about something I wrote on this page, or see an error that needs fixing? Contact me and let me know!

Additional Resources

My original sources for pooling all of this information...

Webinar from P2P

Parent to Parent has an hour-long archived webinar that walks you through the Katie Beckett application in detail, including each of these Physician Forms. You'll submit your email address in order to receive a link to the video, but their emails are worth getting anyway.

Cam & Madi's Promise

Sheila Carter has two special needs kiddos and knows her stuff inside & out. She founded a nonprofit, Cam & Madi's Promise, so she could help parents with this application at no cost. She was an invaluable resource to me and answered dozens of questions on these dizzying forms!

Professional Advocate

If you'd like a professional to help you complete these forms, consider engaging with a professional advocate that does this for a living. Debbie Dobbs comes highly recommended. She does charge a fee but she will also save you a ton of time and headache.