DMAS-99 Form: Free Fillable PDF (rev. 09/26)
The Virginia DMAS-99 Community-Based Care Member Assessment, current revision 09/26, with typeable fields. Download it free, with no sign-up. DMAS requires this version as of October 1, 2026.
Download the fillable DMAS-99 (PDF)
What is the DMAS-99?
The DMAS-99 is the Community-Based Care Member Assessment used in Virginia's CCC Plus Waiver. The RN or LPN supervisor (for agency-directed services) or the Services Facilitator (for consumer-directed services) completes it on the initial visit, on routine supervisory visits, and at every six-month reassessment for members receiving personal care or respite. It records the member's functional status (ADLs, continence, mobility, orientation and behavior), medical and nursing information, critical incidents, the support system around the member, supervision, and continuity of care.
What's new in the 09/26 revision?
- The Start of Care date was removed from the header, and "Agency Name" is now "Provider Name & Phone #."
- A new question asks whether the member had a physician visit in the last 12 months, with the date and the physician's name.
- New questions ask whether an aide or attendant is a legally responsible individual (LRI), such as a parent of a minor or a spouse.
- Employer of Record name, relationship, and whether they were present at the visit (consumer-directed services).
- Expanded questions on supervision, PERS and medication monitoring, including whether the member is 14 or older.
- Supervisory visits at a 30 or 60 day frequency now need written justification of the medical need.
- Critical incidents are reviewed for the last three months, and the instructions were rewritten.
Tips for completing the DMAS-99
- Check only one box per row in each functional status grid. If ability is unclear, ask the member to demonstrate the task when appropriate.
- On routine visits, the address, date of birth and phone number can be omitted if unchanged, and an unchanged functional status section can be lined through and marked "No Change."
- Health status, medication changes, hospitalizations and therapies must be updated on every visit, even when nothing else changed.
- File the completed DMAS-99 in the member record within 2 weeks of the visit. A paid agency aide may not sign as the caregiver, except an LRI aide.
DMAS-99 questions
Is this the official DMAS-99? It is the current DMAS-99 rev. 09/26 published by Virginia DMAS, with fillable fields added so you can type, save and print it. The official form is also posted on the Virginia Medicaid provider portal.
Can I still use the older DMAS-99? No. DMAS required providers to adopt the new version by October 1, 2026, and says service authorization requests on older versions will be denied.
Do I need a DMAS-97A/B too? Yes, most members also need a DMAS-97A/B plan of care. Get the free fillable DMAS-97AB form (Revised 8/2026).
For a full walk-through of what changed on both forms and why, read Virginia's new DMAS-97 and DMAS-99: what changed in 2026.