Get Dhs 3642

Filling out the Dhs 3642 form online is a crucial step in requesting a care plan certification for emergency medical assistance. This guide will walk you through each section of the form to ensure it is completed accurately and efficiently.

Follow the steps to complete the Dhs 3642 form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Provide the assigned authorization number from MN–ITS if applicable. This number should be included in the designated field at the top of the form.
3. Fill in the requested start date for the emergency medical assistance care plan certification. Ensure this date is clear and precise.
4. Complete the recipient information section. This includes the recipient's last name, first name, middle initial, MHCP recipient ID number, state, ZIP code, birthdate, address, city, and phone number.
5. Complete the provider information section with the provider's name, NPI number, address, city, state, ZIP code, contact name, fax number, phone number, and email address.
6. If applicable, fill out the guardian or responsible party information. Include the last name, first name, middle name, address, city, state, ZIP code, and phone number.
7. In the ICD-10 diagnosis code section, provide the relevant emergency diagnosis codes along with their descriptions.
8. Indicate the date of the emergency room or inpatient hospitalization in the specified field.
9. Describe the plan of care, detailing how the treatment services are necessary for the recipient's health and the immediate risks if these services are not provided.
10. If the recipient is in a nursing facility, include the admission date, expected discharge date, and RUG code as applicable.
11. Check all applicable medical documentation that is being submitted to support the EMA CPC request.
12. Confirm whether the patient is currently hospitalized and awaiting discharge. Make sure to select 'Yes' or 'No' in the provided section.
13. In the physician or dentist information section, complete all fields including clinic name, address, the physician or dentist's name, phone number, and provide a signature with the date confirming the information is accurate.
14. Finally, review the form for any incomplete fields, as omissions can lead to administrative denial. Once completed, save changes, download, print, or share the form as needed.

Complete your Dhs 3642 form online today to ensure your request is processed swiftly!