Get Pa Dhs Ma 372 2016-2025

The PA DHS MA 372 form is an essential document for certifying terminal illness for individuals seeking hospice care. This guide will help you understand and accurately complete each section of the form through an online platform.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in the recipient number in field 1, which identifies the patient within the system.
3. Proceed to field 2 and enter the full name of the recipient, referred to as the 'Patient.' Ensure correct spelling for official records.
4. In field 3, provide the written diagnosis of the patient's condition. Be specific about the disorder as it will be assessed for eligibility.
5. Enter the corresponding ICD/CM diagnosis code in field 4. This code is crucial for medical billing and records.
6. For field 5, indicate whether this is the initial certification or a recertification by checking the appropriate box.
7. The attending physician must sign the form in field 6, acknowledging their professional opinion regarding the patient’s life expectancy.
8. In field 7, the date should be added next to the physician's signature to mark when the certification was completed.
9. Field 8 requires the signature of the medical director, ensuring the review and validation of the certification.
10. Field 9 needs the signature of the interdisciplinary team physician, reinforcing the collaborative nature of patient care.
11. Finally, write the date in field 10 to complete the certification process.
12. Once all fields are filled out correctly, users can save changes, download, print, or share the completed form as necessary.

Complete your documents online today to ensure timely processing.