| Label | Type | Description | Mandatory |
| Updated On | CURAM_DATETIME | The date on which the last update was made to the evidence. | No |
| Effective Date of Change | CURAM_DATE | Date which the evidence becomes effective | No |
| Approval Requested | CURAM_INDICATOR | Approval Requested | No |
| Institution Type | EVD_MEDICAL_INSTITUTION_TYPE | Dropdown list containing institution types, e.g., hospital, inpatient rehabilitation center. Only one of institution type or waiver type may be selected. | No |
| Waiver Type | EVD_MEDICAL_INSTITUTION_WAIVER_TYPE | Dropdown list containing waiver program types, e.g., brain injury waiver. Home and community based waivers provide medical assistance funds to help people who would be eligible for nursing home care to remain in their own homes or other community-based settings. Only one of institution type or waiver type may be selected. | No |
| Entered Date | CURAM_DATE | The date on which the individual entered the medical institution or waiver program. | No |
| End Date | CURAM_DATE | The date on which the individual left the medical institution or waiver program. | No |
| Expected Length Of Stay | EVD_MEDICAL_INSTITUTION_EXPECTED_LENGTH_OF_STAY | Dropdown list containing a list of periods that the individual is expected to stay in the medical institution or on the waiver program. | No |
| Medical Institution/Service Provider | FULL_NAME | You can select the medical institution or service provider from the organization's registered participants. To select the medical institution or service provider from the organization's registered persons, press the Search button to open the Person Search pop-up window. On the Person Search pop-up window, enter some or all of the person search criteria and press the Search button to search for persons with matching details. Click the Select link on the appropriate row from the list of persons displayed to select the policyholder. The system automatically creates an additional case participant role of "Medical Institution/Service Provider". | No |
|
| Updated By |
| Label | Type | Description | Mandatory |
| Updated By | USER_NAME | | No |
|
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|
| Medical Institution Details |
| Label | Type | Description | Mandatory |
| Household Member | FULL_NAME | Household member to who stayed in a medical institution or participated in a home and community based waiver program, from the drop-down list of household members. Note that the system displays the primary alternative ID of each of the members displayed on the drop-down list. In the US, the primary alternative ID is the social security number (SSN). | No |
|
| Undue Hardship Details |
| Label | Type | Description | Mandatory |
| Undue Hardship Reason | EVD_MEDICAL_INSTITUTION_UNDUE_HARDSHIP_REASON | Dropdown list containing reasons to prove undue hardship, e.g., at risk of death. | No |
| Certified On | CURAM_DATE | The date on which the reason for undue hardship was certified by a recognised authority. | No |
|
| Placed In Institution By Details |
| Label | Type | Description | Mandatory |
| Placed By Type | EVD_MEDICAL_INSTITUTION_PLACED_BY_TYPE | Dropdown list containing a list of types of people who may have placed the applicant in an institution or on a home and community based waiver, for example, parent, gaurdian. | No |
| Placed By | FULL_NAME | You can select the individual or organization who placed the individual in the institution from the organization's registered persons. To do this, press the Search button to open the Person Search pop-up window. On the Person Search pop-up window, enter some or all of the person search criteria and press the Search button to search for individuals or organizations with matching details. Click the Select link on the appropriate row from the list of persons displayed to select the placer. The system automatically creates an additional case participant role of "placer". | No |
| Placer's State Of Residence At Placement | EVD_ADDRESS_STATE | Dropdown list containing a list of states. From this list you can select the state of residence of the placer at the time the individual was placed in the institution. | No |
|
| Application Filed By Details |
| Label | Type | Description | Mandatory |
| Application Filed By Type | EVD_MEDICAL_INSTITUTION_APPLICATION_FILED_BY_TYPE | The type of individual or organization who filed the application. | No |
| Application Filed By | FULL_NAME | You can select the individual or organization who filed the application from the organization's registered persons. To do this, press the Search button to open the Person Search pop-up window. On the Person Search pop-up window, enter some or all of the person search criteria and press the Search button to search for individuals or organizations with matching details. Click the Select link on the appropriate row from the list of persons displayed to select the individual or organization who filed the application.The system automatically creates an additional case participant role of "Application Filer". | No |
|
| Comments |
| Label | Type | Description | Mandatory |
| Comments | COMMENTS | | No |
|
