Maine DHHS Provider Portal - Transfer

For Deceased MAINECARE Members only
If not a MaineCare Member, DO NOT COMPLETE THIS FORM
* = Required Field

Member Information
First Name:	* Required Field *
Middle Name:
Last Name:	* Required Field *
MaineCare #: (12345678A or 12345678T)	* Required Field * 12345678A or 12345678T *
Facility/Agency Information
Facility Name:	What if my agency is not in the drop-down list?
Phone: (xxx-xxx-xxxx)	* Invalid phone number * Required Field *
Fax: (xxx-xxx-xxxx)	* Invalid fax number
Contact Name:
E-Mail:	* Invalid e-mail address *
Deceased
Date of Death: (mm/dd/yyyy on or before today's date) * Invalid date: use mm/dd/yyyy. Must be today or earlier. *
Location at time of death: * You must indicate location of death Not Selected PNMI/AFCH Hospital NF

Aging & Disability Services