NAME PROVIDER NPI SERVICE TYPE ACTUAL LEVEL OF CARE PROVIDED SERVICE(S) RECIPIENT IS RECEIVING OR REFERRED TO REASON FOR VARIANCE (if applicable) I. Risk of Harm 1. Minimal 2. Low 3. Moderate 4. Serious 5. Extreme IV-B. Recovery Environment – Level of support 1. Highly Supportive 2. Supportive 3. Limited Support 4. Minimal Support 5. No Support II. Functional Status 1. Minimal 2. Mild 3. Moderate 4. Serious 5. Severe V. Treatment and Recovery History 1. .
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How to use or fill out the MN DHS-6249-ENG online
The MN DHS-6249-ENG form, also known as the LOCUS Recording Form, is a vital tool for mental health providers in Minnesota. This guide will walk you through the process of completing this form online, ensuring that you understand each component necessary for accurate submission.
Follow the steps to successfully fill out the MN DHS-6249-ENG online.
- Click the ‘Get Form’ button to obtain the MN DHS-6249-ENG and open it in your browser.
- Fill in the date of assessment. This should reflect the exact date when the LOCUS assessment was completed.
- Input the recipient's date of birth using the format Month/Day/Year (MM/DD/YYYY).
- Select the recipient's gender. Choose either 'Male' or 'Female' as appropriate.
- Provide the recipient's PMI or Social Security number. It is preferable to use the PMI number.
- Enter the primary diagnosis in full or use the corresponding ICD code.
- Complete the section on reason for variance, if applicable. Briefly justify any difference between the recommended level of care and the actual level of care.
- For each dimension being evaluated, select the appropriate rating and document the criteria used to determine that score.
- Calculate the composite score by adding the scores from each dimension.
- Fill in the provider's name, NPI, and the type of service being offered.
- State the level of care recommendation based on the composite score.
- Document the actual level of care received by the recipient.
- List any services or programs the recipient is currently receiving or has been referred to.
- Complete the signature fields at the bottom of the form, ensuring all necessary signatures are provided.
- After all fields are filled, review for accuracy. Save changes, download, print, or share the form as needed.
Complete your MN DHS-6249-ENG online to ensure accurate documentation and care.
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