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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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