Get Mi Dhhs Dch-3877 2021-2025

The MI DHHS DCH-3877 form is essential for identifying individuals who may require further evaluation for mental illness or intellectual/developmental disabilities when being admitted to nursing facilities. This guide provides a step-by-step approach to efficiently fill out the form online, ensuring all necessary information is captured accurately.

Follow the steps to effectively complete the MI DHHS DCH-3877 form.

1. Click the ‘Get Form’ button to obtain the MI DHHS DCH-3877 form online and open it in your document editor.
2. In Section I, carefully enter the patient's information, including their name, date of birth, gender, and address. Ensure you provide the correct county of residence and social security number.
3. Complete the details regarding the legal representative if applicable. Indicate whether the patient has a court-appointed guardian or legal representative, and fill in their name, address, and contact information.
4. Fill in the referral agency's name and telephone number, along with the admission date to the nursing facility and the facility's name and address.
5. Proceed to Section II, which consists of several screening criteria. For each of the six items, select 'Yes' or 'No' based on the patient's condition. Provide explanations for any items answered 'Yes' to ensure clarity.
6. In Section III, the clinician must verify the accuracy of the information provided by signing and dating the form. They should also print or type their name, provide their address, degree, license, and contact number.
7. Once all sections are completed, review the form for any missing information. Save your changes and proceed to download, print, or share the completed MI DHHS DCH-3877 form as necessary.

Ensure you complete the MI DHHS DCH-3877 form online today for proper evaluation and necessary support.