Get Dm5 Form

The Dm5 Form is an essential document used for authorizing Medicaid payments for various types of facility care. This guide provides clear, step-by-step instructions for filling out the Dm5 Form online, ensuring that all users can complete it accurately and efficiently.

Follow the steps to fill out the Dm5 Form online:

1. Click the 'Get Form' button to access and open the Dm5 Form in your online editor.
2. Enter the first and last name of the client in the designated field.
3. Provide the client's 11-digit Nebraska Medicaid number. Ensure this number is accurate to avoid processing delays.
4. Input the name of the Billing Provider along with the facility name if applicable (for example, hospice/facility name).
5. Fill in the complete address of the Billing Provider, ensuring it fits correctly into the specified format for mailing purposes.
6. Enter the 10-digit National Provider Identifier (NPI) of the Billing Provider, as well as the 10-digit Taxonomy Code, both essential for Medicaid records.
7. Include the 9-digit Zip Code of the Billing Provider to ensure proper handling.
8. If you are a staff member from DHHS or the Area Agency on Aging, enter the three-digit care level for the client in the provided section.
9. Sign and date the form where required, ensuring that all signatures are appropriately documented.
10. For physicians, attach any necessary medical documentation and certify the need for care by signing and entering your MD NPI number.
11. Complete the diagnoses section by entering the primary, secondary, and any tertiary diagnosis codes using valid ICD codes.
12. Fill in the client's admission date, identification screen date, Medicare coverage dates, and any discharge information if applicable.
13. For eligibility determination and payment effective dates, fill in these sections as needed, marking any relevant insurance coverage.
14. Review all entries carefully for accuracy before finalizing.
15. After completing the form, save your changes, and use options available to download, print, or share the completed form as necessary.

Start completing your Dm5 Form online now to ensure a smooth authorization process.