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The maximium period of time that can be entered on a single DOH-4471 form is 90 days. This can be a combination of retroactive current and prospective coverage. PAGE 1 Please read the definition of an emergency medical condition on page one of the DOH-4471 form. Fill in the spaces for the patient s name Client Identification Number CIN date of birth address city state and zip code. Only the treating physician may sign the physician s certificatio.

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How to fill out the Doh 4471 Form online

The Doh 4471 Form is an essential document for certifying treatment of an emergency medical condition for Medicaid coverage. This guide provides a step-by-step overview to help you accurately complete the form online, ensuring that all necessary information is provided.

Follow the steps to complete the Doh 4471 Form online.

  1. Click ‘Get Form’ button to obtain the form and open it in the editor.
  2. Fill in the patient's name, including last name, first name, and middle initial. Enter the date of birth in the format MM/DD/YY.
  3. Enter the Client Identification Number (CIN) if available.
  4. The physician must check the appropriate box indicating whether the treatment meets or does not meet the definition of an emergency medical condition.
  5. Provide the name of the provider or facility, along with the complete address and MMIS ID Number or NPI.
  6. On the second page, ensure the applicant or authorized representative signs the 'Authorization to Release Medical Information' in their preferred language.

Start completing your Doh 4471 Form online today to ensure prompt processing of your Medicaid coverage.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate WorkFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232