Get Form Dms 694

Filling out the Form DMS 694 is essential for billing Child Health Services. This guide offers a clear and supportive walkthrough of each section of the form, ensuring accuracy and completeness in your claims process.

Follow the steps to accurately complete the Form DMS 694 online.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. In Section I, begin with the patient identification. Enter the patient's last name in field 1, first name in field 2, and middle initial in field 3. Select the appropriate sex in field 4 by checking 'M' for male or 'F' for female.
3. Provide the patient's Medicaid ID number in field 5 and the date of birth in field 8 using the month, day, and year format. Also, enter the county of residence in field 7.
4. Fill in the street address and city of residence in fields 9 and 10, respectively. If applicable, name the referring physician in field 11.
5. In section I, provide the medical record number in field 12, and the provider's name, address, and provider number in field 13.
6. If there is other health insurance coverage, detail it in field 14. Indicate whether the condition was employment-related or accident-related in fields 15A and 15B, respectively.
7. Enter the primary diagnosis or nature of injury description in field 16, and provide the diagnosis code.
8. In Section II, the examination report must be completed by the screening provider. Check the appropriate box for each test or assessment performed in field 20, and include additional comments in field 21.
9. Detail the dates of service and place of service in fields 22A and 22B. Describe the procedures and enter corresponding codes in field 22C.
10. Include the total charges for services rendered in field 23, and indicate any amounts covered by insurance or the balance due in fields 24 and 25, respectively.
11. Finally, ensure that the provider's signature is entered in field 26, along with the billing date in field 27. Review the information for accuracy before finalizing.
12. Once the form is completed, save the changes, and download or print the document for submission.

Complete your documents online today for streamlined processing and efficiency.