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Maine Department of Health & Human Services

New Admit For MAINECARE Members only
If not a MaineCare Member, DO NOT COMPLETE THIS FORM
Member Information
MaineCare #:
Facility/Agency Information
Facility Name:  
Type your facility name only if it is not in the drop-down list.
Admission Information
Is this a transfer from another nursing facility?
Special Notes
Submission Authorization:
Access Code:
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