Get Dhmh 3871b - Additional Information Form.rtf

The DHMH 3871B - Additional Information Form is essential for providing detailed medical information necessary for determining the level of care. This guide will assist you in accurately completing the form online, ensuring that all necessary information is captured effectively.

Follow the steps to fill out the form correctly.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Begin by filling in the Demographics section. Enter the last name, first name, middle initial, Social Security number, Medical Assistance number, and date of birth. This information identifies the individual for whom the form is being completed.
3. Provide the primary diagnosis in the designated field. If there are secondary or surgical diagnoses that require medical or nursing intervention, list those in the following section.
4. In the section labeled 'Other Pertinent Findings,' include any additional information such as signs, symptoms, complications, or relevant lab results that may affect the person's care.
5. Address the hospitalization question by indicating if there have been any hospitalizations in the last three months, and if so, provide the reasons for each hospitalization.
6. Complete the dietary information section including details about the person’s diet, any supplements taken, height, weight, and blood pressure. Also, indicate if there have been any recent changes and provide explanations as necessary.
7. List any medications the person is taking, including the dosage, frequency, route of administration, and reason for taking it. If any medications are new or have been frequently adjusted, detail these changes in the space provided.
8. Finally, provide any other medical information that is pertinent to the need for a level of care in the designated section.
9. Obtain the signature of a physician or nurse along with the date to complete the form.
10. Once all required fields are filled out accurately, ensure to save changes, download, print, or share the completed form as necessary.

Make sure to complete your documents online efficiently.