Get Mn Dhs-1503 2017-2025

Filling out the MN DHS-1503 form online can streamline the process of securing long-term care services. This guide provides step-by-step instructions to help you navigate each section of the form effectively.

Follow the steps to complete the MN DHS-1503 form online

1. Press the ‘Get Form’ button to download the MN DHS-1503 form and open it for editing.
2. In Section 1, enter the provider information: fill in the long-term care (LTC) provider's name, phone number, and address. Include the National Provider Identifier (NPI) and optional reference number if applicable.
3. In Section 4, write the date when you are completing the form. In Sections 5 and 6, enter the name of the attending physician and their NPI.
4. Section 11 requires the date of admission or readmission to the facility. In Section 12, provide the recipient's Medical Assistance number and their name (last, first, initial).
5. Complete Section 15 with the recipient's birthdate and gender, marking 'F' for female or 'M' for male.
6. In Section 17, describe the primary diagnosis or reason for admission along with the corresponding diagnosis code in Section 19. If applicable, list secondary diagnosis information in Sections 20 and 21.
7. In Section 22, indicate whether the person was screened prior to admission and provide details such as the screening date and agency name if applicable.
8. Fill out the admission information in Sections 24 to 28, which includes the recommended level of care, length of stay, and the source of admission.
9. Sections 38 to 42 require the physician's signature and date. Ensure to provide the county name and any signatures from local county agency representatives.
10. After completing all sections, you can save your changes, download, print, or share the form as needed.

Begin filing your MN DHS-1503 form online for efficient processing of long-term care services.