Get Mn Dhs-4691-eng 2014-2025
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How to fill out the MN DHS-4691-ENG online
This guide provides clear and comprehensive instructions for filling out the MN DHS-4691-ENG online. It is designed to assist users in accurately completing the PCA Time and Activity Documentation form, ensuring proper submission and compliance.
Follow the steps to correctly complete the MN DHS-4691-ENG form.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Enter the PCA agency name and phone number at the top of the form. This information is essential for proper identification.
- Document the dates of service. Use the format MM/DD/YY, and ensure the dates are in consecutive order. If any services were not provided on specific dates, have the recipient draw a line through those entries.
- For each service date, initial next to each activity performed, such as dressing, grooming, bathing, eating, transfers, mobility, positioning, toileting, health-related tasks, behavior, and IADLs. Initial only once per activity, even if it was provided multiple times in one day.
- Indicate the ratio of PCA to recipient by circling the appropriate option (1:1, 1:2, or 1:3) for each visit. This provides clarity on the level of care provided.
- Record the time in and time out for each visit. Use hours and minutes and specify AM or PM by circling the correct option.
- Calculate the daily total time spent in minutes. Ensure the totals for each visit are documented in the specified sections.
- In the acknowledgement and required signatures section, have the recipient and PCA sign and date the form. Ensure all information is accurate before submission.
- Once completed, save changes, download, print, or share the form as necessary.
Start filling out the MN DHS-4691-ENG online now for easy and efficient documentation.
To qualify for PCA services, you must demonstrate a need for assistance with daily activities, as outlined in the MN DHS-4691-ENG form. Eligibility often includes having a specific medical condition or disability that impacts your ability to live independently. Each case is evaluated individually, so it’s important to provide accurate and complete information when applying. Once your application is submitted, you will learn what additional documentation might be necessary.
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