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Get Mn Dhs-4469-eng 2010-2026
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How to use or fill out the MN DHS-4469-ENG online
This guide provides step-by-step instructions for completing the MN DHS-4469-ENG, the Individual PCA Enrollment Application. Designed to support agencies in enrolling individual personal care assistants, this guide will help you navigate each component of the form.
Follow the steps to fill out the MN DHS-4469-ENG online effectively.
- Click ‘Get Form’ button to access the MN DHS-4469-ENG form in the online editor.
- Begin by marking whether this application is for a new hire, a rehire, or if the individual was previously used for Managed Care Organization claims only. This will guide the processing of the application.
- In the 'Individual PCA Information' section, fill in the legal name of the individual, including first, middle, and last names. Provide the individual's Social Security number, phone number, and residential address, ensuring you do not use a P.O. Box.
- Enter the county of residence, zip code, date of birth, and the date DHS training was completed. Include the training certification number. Also, indicate if the individual is 18 years or older by selecting 'Yes' or 'No.'
- Answer whether the individual has maintained continuous employment with your agency since the Background Study (BGS) was completed, and if not, provide the employment end date.
- Review and ensure all provided information is accurate. The individual PCA must certify the truthfulness of the information by signing and dating the form. This is crucial for compliance with the Minnesota Department of Human Services.
- If applicable, indicate whether you want to affiliate the individual PCA with any other agency you own, and enter the required agency details.
- Finally, complete the 'Agency Information' section where you include the agency name, agency NPI/UMPI, agency fax number, and the name and signature of the agency personnel completing the form.
- After reviewing all sections for accuracy, save your changes to the form. You can then download, print, or share the completed application.
- Fax both the completed application and the MHCP Provider Agreement (DHS-4611) to the number provided in the instructions to finalize the enrollment.
Complete your forms online today to streamline the enrollment process for individual personal care assistants.
Yes, a family member can serve as a PCA in Minnesota, provided they meet the necessary qualifications and undergo the required training. However, they must still comply with the MN DHS-4469-ENG regulations for caregivers. This option can be a comforting choice, allowing family members to provide personalized care tailored to individual needs.
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