Get Dhs 54a

This guide provides a clear and concise approach for users to fill out the Dhs 54a, also known as the medical transportation statement. By following the step-by-step instructions, users can efficiently complete the form online while ensuring all necessary information is accurately recorded.

Follow the steps to fill out the Dhs 54a form effectively

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In section I, the MDHHS specialist will complete the following fields: their name, authorized rate, patient or beneficiary's name, MDHHS case number, county number, district number, phone number, level of care code, beneficiary ID number, and the patient’s street address, phone number, city, state, and ZIP code.
3. In section II, the medical provider completes their name, NPI number, phone number, address, and must indicate if the patient has a chronic, ongoing illness. They also need to confirm if someone needs to accompany the patient, whether an overnight stay is required, and the name of the referring physician.
4. In section III, the transportation provider fills in their name, social security number or ID number, type of transportation, complete address, and phone number. They should indicate any other expenses related to transportation.
5. In section IV, the transportation record must be completed for each visit. Enter the appointment date, departure time, return time, round trip miles, and other expenses. Each party involved (beneficiary, transporter, and medical provider) must sign to verify the accuracy of the provided information.
6. In section V, the MDHHS specialist calculates the total number of miles and applies the appropriate rate. They will sign and date the section, while the MDHHS manager reviews and approves the form.
7. Lastly, save the completed form, download it for your records, print a copy if needed, or share it with the relevant parties.

Complete the Dhs 54a form online today for efficient processing of your medical transportation.