Get Hcfa 486 Form

This guide provides clear, step-by-step instructions for filling out the Hcfa 486 form online. It is designed to help people understand the components of the form and ensure accurate completion for effective processing.

Follow the steps to complete the Hcfa 486 form online effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with entering the patient's HI claim number as it appears on the Medicaid ID card. This ensures correct patient identification.
3. Enter the date your agency started providing Private Duty Nursing (PDN) for the patient. This date is essential for establishing the service timeline.
4. Fill in the certification period by specifying the last dates of approval for PDN services, from the beginning date through the renewal date.
5. Provide your agency's seven-digit PDN provider number to identify your agency accordingly.
6. Input the patient's name and address as they appear on the Medicaid ID card to ensure consistency.
7. Enter your agency’s name as it is listed in the Medicaid PDN provider agreement for accurate records.
8. For this form, leave the Medicare covered section blank as it is not applicable.
9. Document the date when the physician last examined the patient, using the month, day, and year format.
10. If applicable, include the dates of any recent inpatient stays where the patient was hospitalized. This information helps to provide context for current service needs.
11. Use the updated information section to summarize the PDN services during the last certification period, noting any important clinical facts.
12. Conclude by indicating the name and title of the nurse completing the form and the date the form was finalized to confirm responsibility.
13. Once all sections are completed, review the form for accuracy, and save changes before downloading, printing, or sharing as needed.

Start completing your Hcfa 486 form online today for efficient processing of your Patient's care!