Get Pa 4 Form

The Pa 4 Form, also known as the Physician Certification, is a crucial document for Medicaid applicants requiring skilled nursing home care or home and community-based waiver services. This guide provides comprehensive steps for completing the form online, ensuring that users can successfully navigate each section.

Follow the steps to complete the Pa 4 Form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the top portion of the form, which requests the individual's full name, home address, phone number, date of birth, veteran status, social security number, and Medicaid number. This information establishes the identity of the person requiring care.
3. Provide the name and contact information of the individual's primary contact person, which helps in facilitating communication regarding care needs.
4. Document the primary and any secondary diagnosis of the individual in the designated section. This specifies the medical conditions that necessitate care.
5. List all prescribed medications along with any 'as needed' (PRN) medications to ensure comprehensive understanding of the individual's treatment plan.
6. Outline all therapies or treatments that have been ordered by physicians to provide a complete picture of the individual's medical care.
7. Describe any physical limitations the individual may have, detailing how these restrictions affect their daily living activities, such as mobility and self-care.
8. Indicate whether the individual has emotional or behavioral issues and whether they require counseling or supportive therapy, as appropriate for their care.
9. Confirm if the individual requires treatment for active tuberculosis or has symptoms diagnosed by a healthcare provider.
10. Select whether the individual needs active treatment for mental illness and if they require care for developmental disabilities or mental retardation.
11. Assess if there is a reasonable indication that the individual might require hospitalization or nursing home care within the next 30 days without home and community-based services.
12. After filling out all required fields, the physician must print their name, address, and phone number. The form must then be signed and dated in the designated areas.
13. Once completed, review the form for accuracy and then return or submit the form to the appropriate County Welfare Agency.

Ensure you complete the necessary documents online for efficient processing.