Get Mn Dhs-2780-eng 2011-2025

Filling out the MN DHS-2780-ENG form online requires careful attention to detail to ensure that all necessary information is accurately provided. This guide offers step-by-step instructions to help you navigate through each section of the form with confidence.

Follow the steps to complete the MN DHS-2780-ENG form online.

1. Click ‘Get Form’ button to access the MN DHS-2780-ENG form and open it in the appropriate editor.
2. Enter the agreement start date in the format MM/DD/YYYY. This date marks the beginning of the service agreement.
3. Provide the PMI number (recipient ID) so that the service can be tracked accurately.
4. Fill in the agreement end date, also in MM/DD/YYYY format, to indicate when the services will conclude.
5. Complete the client name by entering the last name, first name, and middle initial.
6. If the client has an alias, list it in the designated field.
7. Enter the client’s date of birth in MM/DD/YYYY format to verify their age.
8. Select the county or tribe responsible for service delivery.
9. Identify the county or tribe of financial responsibility for the client.
10. Indicate the primary language spoken by the client.
11. Answer the question regarding Hispanic origin by marking 'Y' for Yes or 'N' for No.
12. Provide the date of signature in MM/DD/YYYY format, which confirms the agreement.
13. Collect the authorized county or tribal signature to validate the agreement.
14. Enter the client's Social Security number using the appropriate format.
15. Indicate the client's marital status by selecting the appropriate letter: M, D, N, L, U, or W.
16. Specify the client's gender using 'M' for male or 'F' for female.
17. Check the box if the client does not wish to receive a notification letter.
18. Fill in the service agreement number, which helps in tracking the service.
19. Complete the client’s residential address, including street address, city, state, and ZIP code.
20. Indicate the race of the client by selecting from the options provided.
21. For the financially responsible person, complete their name (last, first, middle initial).
22. If the financially responsible person’s address differs from the client’s address, provide it.
23. Enter the Rule 25 assessment date in MM/DD/YYYY format.
24. Fill out the assessment severity ratings as required.
25. If the client is a minor, ensure they initial the box authorizing notification letters to be sent.
26. Provide details about the service lines, including procedure codes, modifiers, revenue codes, total amount, and units.
27. Complete the service rates and any necessary provider information.
28. Near the end of the form, there will be fields related to health insurance and employment information.
29. Carefully review all entered information for accuracy before proceeding.
30. Once all sections are completed, users can save changes, download, print, or share the filled form.

Complete your MN DHS-2780-ENG form online today.