Get Mn Dhs-4690 2007

The MN DHS-4690 form, known as the Physician Statement of Need for Personal Care Assistant Services, is essential for establishing the medical necessity of PCA services. This guide will provide you with a comprehensive, step-by-step approach to fill out this form online, ensuring you complete each section accurately and efficiently.

Follow the steps to fill out the MN DHS-4690 online successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin filling out the patient information section by entering the full name of the patient, their date of birth, address, city, state, and zip code.
3. Next, include the patient’s clinic information, which includes the clinic name, telephone number, and fax number.
4. Complete the section for the patient’s physician by providing the physician’s name, contact information, and the clinic address.
5. Indicate the length of time the patient has been under the physician’s care and the date of the last office visit.
6. Answer the question regarding if the patient has a diagnosis or condition that results in the need for PCA services by selecting the appropriate checkbox.
7. If the answer is yes, complete the form and return it to the PCA provider. If the answer is no, complete the form and fax it to DHS as indicated.
8. List the relevant ICD-9 diagnosis codes for the patient in the designated fields.
9. Provide a description of the patient’s need for PCA services or the reasons PCA services are deemed inappropriate. Do not include an hourly amount in this section.
10. Finally, ensure the physician prints their name, signs the form, and dates it before submission.
11. After completing all sections, take a moment to review the form for any missing information, then save changes or download, print, or share the completed form as necessary.

Complete the MN DHS-4690 online to ensure timely access to PCA services.