Get Mn Mhcp Dhs-3642 2019-2025

This guide provides step-by-step instructions on how to accurately complete the MN MHCP DHS-3642 online form for Emergency Medical Assistance Care Plan Certification. It is essential to provide complete and correct information to ensure timely processing of your request.

Follow the steps to complete your application successfully.

1. Utilize the ‘Get Form’ button to access the form and open it in a suitable editor.
2. Begin by filling out the assigned authorization number from MN–ITS, if applicable. This number helps connect your request to previously submitted services.
3. Indicate the requested start date for the Emergency Medical Assistance Care Plan Certification; this is when you want the assistance to begin.
4. Complete the member information section thoroughly. Include the last name, first name, middle initial, address, city, state, zip code, date of birth, and phone number of the person receiving assistance.
5. In the provider information section, fill in the provider's name, National Provider Identifier (NPI), address, contact name, phone number, fax number, and email address. Ensure all fields are accurately completed.
6. If applicable, provide information about the guardian or responsible party, including their last name, first name, address, city, state, zip code, and phone number.
7. Input the ICD diagnosis code(s) and a brief description of the emergency medical diagnosis(es). Only include diagnoses that qualify for emergency medical assistance.
8. Indicate the emergency room or inpatient hospitalization start and end dates related to the diagnosis. This information helps assess the urgency of the request.
9. In the plan of care section, describe how discontinuing treatment could rapidly worsen the member's condition. Provide specific details regarding required treatments and services.
10. Fill out the nursing facilities information if relevant, including admission and expected discharge dates, as well as the RUG code and a description of the services.
11. Complete the medical information required to process the request by checking all relevant medical documentation to be submitted along with the form.
12. Indicate whether the patient is currently hospitalized and awaiting discharge. Select 'Yes' for expedited processing if applicable.
13. Finally, ensure all sections of the form are complete and verify the entries for accuracy. Save changes, download, print, or share the form as necessary.

Start filling out the MN MHCP DHS-3642 online now to ensure your application is processed without delay.