Get Dma 3137 Icd 10 Transition Form

Completing the Dma 3137 Icd 10 Transition Form is essential for beneficiaries requiring personal care services in North Carolina. This guide provides clear, step-by-step instructions to help users navigate the process of filling out the form online, ensuring all necessary information is submitted accurately.

Follow the steps to complete the Dma 3137 Icd 10 Transition Form online.

1. Click ‘Get Form’ button to access the Dma 3137 Icd 10 Transition Form and open it for editing.
2. Begin by filling out Section A, which includes the beneficiary's demographics. Input the beneficiary's first name, middle initial, last name, date of birth, Medicaid ID number, and gender. Indicate the preferred language and complete the address, city, county, zip code, and phone number.
3. If the beneficiary is under 18, include information for an alternate contact, such as a parent or guardian. Provide their name, relationship to the beneficiary, and phone number.
4. Complete the current PCS provider information, including the provider's name, National Provider Identifier (NPI), and phone number. Indicate where the beneficiary currently resides by checking the appropriate option.
5. In Section B, list the beneficiary’s medical diagnoses related to their need for assistance with Activities of Daily Living. Provide the corresponding ICD-10 codes for each diagnosis in the space provided, ensuring that it adheres to the 4 or 5 digit requirement.
6. Proceed to Section C, where the practitioner information is required. The practitioner must endorse the need for an assessment by providing their name, NPI, practice name, contact information, and signature. Ensure the date of the signature is included.
7. Review all information for accuracy and completeness, ensuring all fields are filled out correctly. Once completed, the form can be saved, downloaded, printed, or shared as needed.

Take the next step and fill out the Dma 3137 Icd 10 Transition Form online to ensure your personal care services are appropriately documented.