Maine DHHS Provider Portal

Discharge For 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)	* 12345678A or 12345678T * Required Field *
Facility/Agency Information
Facility Name:	Type your facility name only if it 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 *
Discharge Information

* Date needs to be MM/DD/YYYY and must be today or earlier *
Home	Address:	Date: * Invalid date: use MM/DD/YYYY and must be today or earlier *
Residential Care	Name:	Date: * Invalid date: use MM/DD/YYYY and must be today or earlier *
Other Nursing Facility	Name:	Date: * Invalid date: use MM/DD/YYYY and must be today or earlier *
HHA	Name:	Date: * Invalid date: use MM/DD/YYYY and must be today or earlier *
Hospice House	Name:	Date: * Invalid date: use MM/DD/YYYY and must be today or earlier *
Hospital	Name:	Date: * Invalid date: use MM/DD/YYYY and must be today or earlier *
		* Invalid date: use MM/DD/YYYY and must be today or earlier *
Special Notes

Submission Authorization:
Access Code:	* Access Code is Required *

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Aging & Disability Services