Get Cshcn Services Program Physcisian/dentist Form. Application

Completing the CSHCN Services Program Physician/Dentist Form is an essential step in accessing health care services for individuals with special health care needs. This guide will provide clear, step-by-step instructions on how to accurately fill out the form online.

Follow the steps to complete your application effectively.

1. Press the ‘Get Form’ button to obtain the form and open it in the appropriate editor.
2. Fill out the applicant information section. Provide the full name (last, first, middle) and select the gender. Then, enter the home address, including city, apartment number (if applicable), county, state, and zip code. Specify the date of birth and include the CSHCN ID number if known. Indicate whether this is an initial application or a renewal.
3. Complete the applicant medical information section. Ensure the applicant meets the criteria for age and health conditions listed. Verify that the form only uses ICD-10 codes with the highest level of specificity. Fill in the primary ICD code, description, and any additional codes and descriptions as necessary.
4. Address the certification of needs. Complete the questions regarding the applicant's health care needs and potential consequences of inadequate care. Provide any relevant details about the complexity or severity of the applicant’s condition. If needed, attach additional pages for further information.
5. In the services section, indicate any non-medical or non-dental services the applicant may require by marking the relevant boxes.
6. Complete the physician/dentist information section by entering their name, specialty, NPI number, phone number, and address.
7. Read the acknowledgment statement carefully. The physician or dentist must sign and date the form to certify the accuracy of the information provided. Ensure the form is returned to the applicant or mailed to the designated address.
8. After completing all sections, save the changes made to the form. You may then choose to download, print, or share the completed form as needed.

Complete your CSHCN Services Program Physician/Dentist Form online today to ensure timely access to essential health services.