Get La Bhsf Form Dip1 2015-2026

The LA BHSF Form DIP1 is a prescription request form designed for disposable incontinence products. This guide will help you navigate through each section of the form to ensure a complete and accurate submission when filling it out online.

Follow the steps to effectively complete the form online.

1. Press the ‘Get Form’ button to access the form and open it in your online editor.
2. Begin by entering the recipient information. Fill in the name, date of birth, age, Medicaid ID, height, weight, and recipient’s address accurately.
3. In the prescribing provider section, input the prescriber’s name, phone number, address, and fax number.
4. Specify the medical diagnoses causing the incontinence by stating the primary and secondary diagnoses along with their corresponding ICD CM codes.
5. Indicate whether the incontinence is urine or fecal. Provide the primary and secondary diagnoses, along with the respective ICD CM codes.
6. Within the mobility section, check the appropriate options that describe the recipient’s mobility assistance needs.
7. If requesting more than eight products per day, make sure to include additional documentation explaining the acute medical condition or extenuating circumstances.
8. Assess the mental status and level of orientation of the recipient by selecting the appropriate option regarding their ability to communicate needs.
9. List any additional supporting diagnoses along with the specific ICD-CM codes.
10. Indicate the frequency of anticipated change during daytime and nighttime.
11. List current supportive services being utilized by the recipient, checking all that apply.
12. Mention any medications or nutritional therapies that may increase urine or fecal output.
13. Specify the incontinence supply needed, including the size, quantity per day, and duration of need. Be sure to select the type of product and size required.
14. The prescriber must sign and date the form, indicating that they have assessed the patient and that the items prescribed are medically necessary.
15. Finally, include any comments or additional documentation if needed. Once completed, ensure to save changes, download, print, or share the form as appropriate.

Complete your documents online to streamline your prescription request process.