The 5615 Form is used as a communication tool between eligibility sites and nursing facilities for all Long-Term Care (LTC) Medicaid clients. Eligibility sites use the 5615 form to calculate the client’s patient payment to the nursing facility. This form is to be completed by eligibility sites and submitted to nursing facilities for all LTC Medicaid clients.

Department of Health Care Policy and Financing · 1570 Grant Street · Denver, CO 80203-1818 · (303) 866-2993 Phone · (303) 866-4411 Fax