Get 6790g Form

The 6790g Form is an essential document for providing accurate client information in prevocational services and structured day programs. This guide offers step-by-step instruction on how to fill out the form online to ensure a smooth and efficient submission process.

Follow the steps to complete the 6790g Form online effectively.

1. Click the ‘Get Form’ button to obtain the form and open it in a digital editor.
2. Enter the provider name in the designated field. This should reflect the official name of the service provider for accurate record-keeping.
3. Fill in today’s date in the relevant section. This indicates when the form is being submitted.
4. Provide the provider contact phone number. Ensure the number is accurate to facilitate communication.
5. Include the provider’s National Provider Identifier (NPI). This unique identification number is crucial for service providers.
6. Enter the recipient’s Personal Medical Identifier (PMI) in the specified section. This helps in tracking individual service records.
7. Fill in the recipient's date of birth to confirm their identity and for age-related service considerations.
8. Indicate the service end date. This denotes the duration of service being requested or reported.
9. Specify the total day units between the start and end dates of service. This metric aids in service assessment.
10. Provide the provider contact email for any follow-up inquiries related to the form.
11. Under general information, enter the recipient’s name to ensure proper identification.
12. Fill in the county of recipient residence. This information is necessary for jurisdictional purposes.
13. State the service start date clearly, marking the beginning of the reporting period.
14. Indicate the average staffing ratio in the provided field to reflect the level of care.
15. Record the average individual direct Licensed Practical Nurse (LPN) hours per day, highlighting the care provided.
16. For customization related to deaf or hard of hearing needs, select 'Yes' or 'No' based on the recipient's requirements.
17. Document the average individual direct Registered Nurse (RN) hours per day.
18. If applicable, enter the transportation amount for daily to/from service using the space provided.
19. After completing all sections, review the form for accuracy. You can then save changes, download, print, or share the completed form as required.

Complete your documentation efficiently — fill out the 6790g Form online today.