Get Dhs 4695 Eng

Completing the Dhs 4695 Eng form online is a necessary step for obtaining authorization for prosthetics and orthotics. This guide provides a clear and detailed approach to assist users in filling out the form accurately and efficiently.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to initiate the process and access the form in your online environment.
2. Begin filling out the provider information section. Input the provider name, NPI/UMPI number, contact name, and phone number, ensuring accurate details for communication.
3. Proceed to the recipient information section. Complete all fields, including last name, first name, middle initial, date of birth, MHCP ID number, primary diagnosis code and description, height, secondary diagnosis code and description, weight, and Medicare functional level assessment.
4. Answer the question regarding whether the recipient currently has a prosthetic or orthotic device by selecting 'yes' or 'no'.
5. If applicable, provide the age of the existing prosthetic or orthotic device and describe its condition, including fit and appropriateness.
6. Indicate how often the current prosthetic or orthotic device is used.
7. After inspection of the current device, specify if any items can be reused, repaired, or replaced. If not, provide an explanation.
8. Indicate if there has been a significant condition change, detailing weight changes, occupational changes, new diagnoses, or medication alterations.
9. State the reason for replacement, choosing between medical or functional, and provide a detailed explanation.
10. List any less costly items that have been tried to meet the recipient’s needs, along with the outcomes.
11. Complete the 'Other important information' section if needed.
12. Finally, secure the signatures of the orthotist/prosthetist and any other professionals involved in the evaluation, including their credentials and date.

Take the next step and complete your Dhs 4695 Eng form online to ensure authorization for necessary prosthetic or orthotic services.