Get Mn Dhs-4690 2010-2025

The MN DHS-4690 form serves as a crucial communication tool for personal care assistance services between healthcare providers and patients. This guide provides step-by-step instructions to help you easily fill out the form online, ensuring that all necessary information is accurately provided.

Follow the steps to complete the MN DHS-4690 form online.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by entering the physician's name and clinic address in the designated fields at the top of the form. This information identifies the healthcare provider involved in the assessment.
3. Next, fill in the recipient's name and date of birth using the format mm/dd/yyyy. This ensures clarity regarding the individual receiving services.
4. Specify the diagnosis of the recipient. This section is crucial as it provides context for the care needed.
5. Indicate the assessment date for PCA services. This documentation helps track the timeline of care.
6. Select the appropriate box to indicate whether the person meets the access criteria for PCA services, and include the determined minutes or hours of PCA services if applicable.
7. In the section for dependencies in activities of daily living (ADLs), check all applicable boxes to detail the specific assistance required by the recipient.
8. Complete the behaviors section by marking any relevant cognitive deficits or behaviors observed that may affect care.
9. For complex health-related needs, check all necessary procedures and interventions, ensuring comprehensive care needs are documented.
10. In the referrals portion, outline any services or supports recommended for the recipient, ensuring they are aware of available resources.
11. Include the assessor's name, the date of completion, and contact telephone number to finalize the form. This provides a point of contact for any necessary follow-up.
12. Once all sections are completed, review the form for accuracy, and then save changes. Users can choose to download, print, or share the completed form as needed.

Complete the MN DHS-4690 form online today to ensure timely and effective care for individuals in need.