Get Dma-3165-iapdf Notification Of Hospice And Personal Care Services Pcs Coordination Form - Info Dhhs

This guide provides detailed instructions for completing the Dma-3165-iapdf Notification Of Hospice And Personal Care Services PCS Coordination Form, helping users to navigate the online process effectively. Whether you are familiar with digital forms or new to them, this comprehensive guide will assist you in successfully submitting your form.

Follow the steps to complete the form accurately and efficiently.

1. Click ‘Get Form’ button to access the form and open it in the online editor.
2. Enter the date of request in the designated field at the top of the form.
3. Fill in the recipient information, including their last name, first name, middle initial, recipient ID, date of birth, phone number, and address. Indicate if a translator is required and specify the language.
4. Provide the names of the attending medical doctor and the hospice medical doctor. If the responsible party is different from the recipient, include their name and contact phone number.
5. Indicate whether the recipient has utilized personal care services in the past by selecting 'Yes,' 'No,' or 'Unknown.'
6. Fill out the hospice agency information by providing the name, NPI, phone, fax, contact name, and contact phone.
7. Input the PCS agency information. If not yet assigned, it will be added by DMA when allocated.
8. Describe the service gap, detailing the needs that require involvement from both providers, such as specific health or personal care needs.
9. In the activities of daily living section, indicate the responsible party for each service by entering 'H' for hospice, 'F' for family, or 'P' for the PCS provider. Use 'AM,' 'Mid,' and 'PM' to specify service times.
10. Both the beneficiary or representative and the hospice representative must provide their signatures and date the form at the end.
11. Once completed, ensure to review all entries for accuracy before proceeding to save changes, download, print, or share the form.

Complete your Dma-3165-iapdf Notification Of Hospice And Personal Care Services PCS Coordination Form online to ensure timely processing and care coordination.