Get Dc Amerihealth Caritas 5400acdc-17222

This guide provides a comprehensive walkthrough for users filling out the DC AmeriHealth Caritas 5400ACDC-17222 form. Follow these steps for a user-friendly experience to ensure all relevant information is accurately completed.

Follow the steps to successfully complete the form online.

1. Click the ‘Get Form’ button to access the form and open it for editing.
2. Begin with the date field. Enter the current date when the form is being filled out.
3. Provide the member’s name in the designated field. Ensure the name matches official identification.
4. Input the member ID number, which is typically found on their insurance card.
5. Enter the member's date of birth in the specified format. This information is crucial for identifying the individual.
6. Fill in the member's address, including street, city, state, and zip code.
7. Input the member's phone number to ensure effective communication regarding discharge.
8. Specify the name of the facility where the member was treated.
9. Enter the facility's NPI number, which is necessary for billing and identification purposes.
10. Record the date of admission to the facility.
11. Indicate where the member is being discharged to, such as home, foster care, or shelter.
12. Enter the discharge date in the appropriate field.
13. Provide the discharge address if different from the member's home address.
14. Fill in the discharge phone number for the place where the member will be staying.
15. For minors or dependent adults, include the name and contact information of the parent or guardian.
16. List the ICD-10 discharge diagnoses applicable to the member, covering psychiatric, substance use, and medical conditions.
17. Indicate whether the discharge was against medical advice (AMA) by checking 'Yes' or 'No'.
18. State if discharge information was shared with the primary care provider or psychiatrist.
19. Confirm if the discharge plan was discussed with the member.
20. For minors or dependent adults, note if informed consent for psychotherapeutic medication was completed.
21. Check all applicable items that were included in the discharge plan, such as referrals to various services.
22. Document any comments that may help clarify the discharge planning.
23. Indicate if any collaboration is needed with specific agencies and provide contact information.
24. List all discharge medications, providing details on dosage, frequency, and purposes.
25. Answer whether the medications are on the formulary and if they require precertification.
26. Confirm if precertification has been received for any required medications.
27. Conduct a risk assessment, noting the member's stability at discharge regarding potential risks.
28. Enter details for the first aftercare appointment within seven days, including provider name and contact.
29. Describe whether a second aftercare appointment is scheduled and provide relevant details.
30. List any other providers involved in the aftercare plan, including their contact information.
31. Complete the form by entering the name and phone number of the person submitting the form.
32. Finally, review all provided information for accuracy before saving, downloading, or printing the completed form.

Complete your DC AmeriHealth Caritas 5400ACDC-17222 form online today for efficient document management.