Understanding the Maryland Medicaid Form 3871: What It Is, Who Needs It, and How to Complete It. Advice from Senior Care Advisors.

Navigating Medicaid requirements can be complex, especially when it comes to long-term care planning for older adults. One key document many families encounter in Maryland is the Medicaid Form 3871, officially known as the Medical Eligibility Review Form. This form plays an important role in determining whether someone qualifies for specific levels of care through the Maryland Medical Assistance Program.1 

 

What Is the Maryland Medicaid Form 3871?

The Form 3871 is a detailed medical eligibility review document used by the Maryland Medical Assistance Program to assess whether an individual needs certain Medicaid-covered services, such as nursing facility care, rehab hospital services, medical day care, or other specialized care.2

The form collects critical information about:

  • The level of care or services requested

  • Patient demographics

  • A physician’s plan of care

  • Functional and cognitive status assessments

  • Physician certification of the need for care3

Because Maryland’s Medicaid program covers services linked to specific care needs, this form helps ensure that applicants are evaluated accurately and consistently 4.

Who Needs to Complete It?

1. Individuals Seeking Medicaid-Funded Long-Term Care

If someone is applying for Medicaid benefits related to long-term care services — particularly institutional care like a nursing facility — Form 3871 is typically required. (Maryland.gov Enterprise Agency Template) This includes adults who need help with daily activities, rehabilitation, or ongoing medical support.

2. Patient Representatives

A patient or their designated representative can fill out parts of the form, especially sections about basic information and demographic details 5.

3. Physicians and Medical Providers

Critical sections of the form — especially the Plan of Care and Physician’s Certification — must be completed and signed by a physician or authorized medical professional who understands the patient’s health needs 6.

This collaborative approach ensures that both personal and clinical information are included accurately.

How to Fill Out the Form — Step by Step

Though you’ll want the actual form in front of you when completing it, here’s a general overview of what each section involves:

1. Level of Care/Services Requested

At the top of the form, indicate the specific care being requested — whether that’s:

  • Nursing facility services
  • Rehab hospital
  • Medical day care
    …and enter the relevant application and financial eligibility dates 7.

2. Patient Demographics (Part A)

This section includes:

  • Full name
  • Date of birth
  • Admission date
  • Address
  • Social Security and Medical Assistance numbers
    and information about a patient representative if applicable 8.

3. Physician’s Plan of Care (Part B)

A physician or authorized provider completes this portion, which details:

  • Diagnoses related to the requested level of care
  • Ongoing treatments and medication plans
  • Any therapy or rehabilitation details
    This part forms the clinical justification for why a specific level of care is needed. 9

4. Functional and Cognitive Status (Parts C–E)

Depending on the applicant’s age and care needs, these sections assess:

  • Ability to perform daily activities
  • Cognitive and behavioral status
  • Use of adaptive devices (like walkers or wheelchairs)10

5. Physician Certification (Part F)

Finally, a physician must sign and date this portion, certifying that the level of care requested is medically necessary 11.

After completion, the form is usually reviewed by a state Medicaid eligibility agent who makes the final determination.

Who Can Help You With Form 3871 in Baltimore

Filling out complex Medicaid forms can feel overwhelming — and you don’t have to do it alone. Here are resources that can assist Maryland families:

Maryland Health Connection

The state’s official marketplace offers guidance on Medicaid eligibility and enrollment, including phone support and enrollment help.
Phone: 1-855-642-8572 (Maryland Health Connection)

Local Department of Social Services or Health Departments

You can apply for Medicaid in person and receive help from eligibility workers who understand the process. (Maryland.gov Enterprise Agency Template)

Community Assistance Programs

Organizations throughout Baltimore can assist with filling out forms and understanding eligibility:

  • Franciscan Center of Baltimore — offers case management services and support for individuals in need. (Find Help)
  • Case management and advocacy groups can help guide you through documentation and state processes.

CarePatrol of Baltimore

While CarePatrol doesn’t complete Medicaid paperwork, our local Senior Placement Advisors connect families with the right care options and help them understand the steps involved with Medicaid applications and long-term care planning. Whether you’re exploring assisted living, memory care, or nursing facility care, we’re here to guide you every step of the way. (CarePatrol)

Tips for a Smooth Form Completion

  • Print or type clearly to avoid delays12.
  • Ensure all required fields are complete before submission13.
  • Work with a physician early to complete the Plan of Care and certification14.
  • Don’t hesitate to ask for help from local resources if you’re unsure.

Filling out the Maryland Medicaid Form 3871 might seem intimidating, but understanding its purpose and requirements can make the process feel much more manageable. Whether you’re preparing for a loved one’s long-term care or navigating eligibility for the first time, the right support and accurate completion of this form can pave the way for needed care services.

Works Cited

1-14 (Maryland PDF Forms)

“3871 Maryland Medicaid PDF Template.” MarylandFormsPDF.com, 2026, https://marylandformspdf.com/blank-3871-maryland-medicaid/.
“Medical Eligibility Review Form MD DHMH 3871.” Maryland.gov, 2016, https://health.maryland.gov/mmcp/siteassets/pages/ucatransition/3871%20form%20-%20revised%20jan%202016.pdf.
“Medical Assistance.” Maryland Department of Human Services, https://dhs.maryland.gov/weathering-tough-times/medical-assistance/.
“How to Enroll in Medicaid.” Maryland Health Connection, https://www.marylandhealthconnection.gov/how-to-enroll/medicaid/.
“Help Fill Out Forms – Baltimore, MD.” FindHelp.org, https://www.findhelp.org/care/help-fill-out-forms–baltimore-md.
“CarePatrol of Baltimore.” CarePatrol.com, https://carepatrol.com/baltimore/.