Get Hfs 3867

The HFS 3867 form is essential for evaluating individuals who may need a motorized wheelchair due to mobility limitations. This guide provides step-by-step instructions to help you complete the form accurately and efficiently online.

Follow the steps to successfully complete the HFS 3867 form.

1. Press the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin filling out the 'Resident Name' field by entering the full name of the individual being evaluated.
3. Next, input the 'Recipient Identification Number (RIN)' in the designated area, ensuring that the number is accurate to prevent any processing delays.
4. Enter the 'Nursing Facility Name' where the evaluation is taking place, making sure to include the official name as it appears in documents.
5. Respond to the first question about physical limitations by selecting 'Yes' or 'No.' If 'No' is selected, you will stop here. If 'Yes,' proceed to question 2.
6. For question 2, indicate if the person is unable to perform the listed mobility-related activities. Choose 'Yes' or 'No' for each activity.
7. Continue to questions 3a and 3b, assessing the individual's mental capacity for safe operation of a motorized wheelchair. Select your answers accordingly.
8. Next, answer question 4 regarding the person's physical capabilities for safely using a motorized wheelchair.
9. Finally, in question 5, confirm if the individual consents to a complete evaluation for a motorized wheelchair.
10. Fill in the name and title/position of the person completing the form in the appropriate fields.
11. Sign and date the declaration at the bottom of the form, certifying that the information provided is true and correct.
12. Once all fields are completed, save your changes, and choose to download, print, or share the form as needed.

Complete the HFS 3867 online today to ensure a smooth evaluation process.