Form 2601
March 2020-E
Physician Certification
1. Applicant/Member Name (Last, First, Middle Initial) 2. Medicaid or Applicant Social Security No. 3. Date of Birth
4. Applicant/Member Primary Diagnosis
5. Other Active Diagnoses
6.a. I have personally examined this individual in the last twelve months and reviewed all appropriate medical records. Yes No
6.b. I certify that this individual requires ongoing nursing services under the supervision of a Doctor of Medicine
(MD)/Doctor of Osteopathic Medicine (DO). These services may be provided in either a home or community-
based setting or in a nursing facility.
Yes No
I understand I am not prescribing nursing or other Medicaid services. By signing this form, I certify that the information provided above
is accurate.
Signature of Physician Date of Physician Signature
MD/DO License Number MD/DO License State
MD/DO Name Military Physician
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