Get Mn 4074a 2012

The MN 4074A form is a technical change request for Personal Care Assistance services in Minnesota. This guide provides detailed instructions on how to complete the form online, ensuring you can successfully submit your request.

Follow the steps to complete the MN 4074A online.

1. Click the ‘Get Form’ button to access the MN 4074A form and open it in an online editor.
2. Select the request type by indicating the type of change or correction needed. Fill in the change/start date and end date for your request.
3. Provide information about the provider change. Indicate if there is a new provider, a discontinuing provider, or other changes by selecting the relevant options provided.
4. Enter the recipient information, which includes the complete legal name, Subscriber ID, and date of birth. Choose between PCA Traditional or PCA Choice.
5. Fill out the provider agency information. This should include the agency name, NPI/UMPI, and the name and title of the requestor, along with their phone and fax numbers.
6. If a new provider change is requested, provide the name and relationship to the recipient, along with the signature of the recipient or responsible party and the date change is requested.
7. Enter additional information regarding the request if necessary, including any specific details about the changes.
8. Review all the information for accuracy and completeness. Once satisfied, save changes, download, or print the form for your records.

Complete the MN 4074A form online today to ensure efficient processing of your request.