Get Dss 4449b Rev 4 97

Filling out the Dss 4449b Rev 4 97 is an essential step in providing necessary information about the facility and individual receiving care. This guide offers a straightforward approach to completing the form online, ensuring that all required details are accurately captured.

Follow the steps to complete the Dss 4449b Rev 4 97 online.

1. Click the ‘Get Form’ button to access the Dss 4449b Rev 4 97 form and open it in your preferred editor.
2. Begin by entering the name of the facility in the designated field. Ensure that the name is accurate to avoid any processing delays.
3. Next, provide the start date of care under the ALP section. This date is crucial for tracking the care timeline.
4. Complete the section titled 'Home address (prior to admission)' by entering the street address, city, state, and zip code of the individual receiving care.
5. Fill in the date of birth and social security number of the individual. Ensure the accuracy of these details for proper record-keeping.
6. Input the Medicaid CIN number followed by any Medicare details if applicable, including specifying whether it is Part A or Part B.
7. List any other health insurance information in the provided fields, ensuring that policy numbers and addresses are accurate.
8. Indicate the sources of income or benefits by checking all that apply, including options like SSI, public assistance, pension, or veteran's benefits.
9. Provide details about the next of kin or guardian, including their contact information, relationship to the individual, and burial instructions if necessary.
10. Include any additional health or mental health providers' information, such as names, addresses, and phone numbers.
11. Document the primary physician's contact information and the hospital of choice for the individual.
12. Finally, review all entered details for accuracy. Users can then save the changes, download, print, or share the completed Dss 4449b Rev 4 97 form as needed.

Complete your Dss 4449b Rev 4 97 form online to ensure a smooth application process.