Get Mn Dhs-4691-eng 2014-2025

The MN DHS-4691-ENG form is essential for documenting personal care assistance (PCA) services provided to individuals. This guide will walk you through each section of the form with clear, step-by-step instructions to ensure accurate completion.

Follow the steps to complete the MN DHS-4691-ENG form online.

1. Click the ‘Get Form’ button to access the MN DHS-4691-ENG form and open it in the designated online editor.
2. Enter the PCA agency name and contact phone number in the designated field at the top of the form.
3. Record the dates of service in consecutive order. Use the MM/DD/YY format for each date when services were provided. Make sure to note any hospital, care facility, or incarceration details as needed.
4. In the 'Activities' section, place your initials next to each activity you performed on the specified dates. Activities include dressing, grooming, bathing, eating, transferring, mobility, positioning, toileting, health-related tasks, behavior support, and instrumental activities of daily living (IADLs). Remember to initial only once for multiple occurrences in a day.
5. For each visit recorded, indicate the ratio of PCA staff to recipients (1:1, 1:2, or 1:3) by circling the appropriate option.
6. Document the time of care for both the start and end of each visit, and remember to circle AM or PM for each entry.
7. Calculate the daily total in minutes for the care provided during each visit and enter this total into the appropriate section.
8. In the 'Acknowledgement and Required Signatures' section, the recipient or responsible party should print their name, provide the MA member number or date of birth, sign, and date the form. The PCA must also print their name, provide their PCA NPI/UMPI, sign, and date.
9. Review the completed form for accuracy, specifically ensuring that any dates or times when services were not rendered are crossed out.
10. After verifying all details, users can save changes, download, print, or share the completed MN DHS-4691-ENG form as needed.

Ensure accurate and timely submission of important documents by completing the MN DHS-4691-ENG form online today.