Get Mn 4074a 2017

The MN 4074A form is used to request technical changes to existing personal care assistance service authorizations. This guide provides clear, step-by-step instructions for users to fill out the form online effectively.

Follow the steps to complete the MN 4074A online.

1. Click ‘Get Form’ button to obtain the MN 4074A form and open it in your editor.
2. Select the type of request you are making under the 'Request Type' section. Examples include changes to a start date or ending date, provider changes, or requests for a duplicate copy.
3. Fill in the 'Change/Start Date' and 'End Date' fields accurately. This indicates the period during which the requested changes will take effect.
4. In the 'Recipient Information' section, enter the recipient's complete legal name, Subscriber ID (also known as MA number), date of birth, and select either PCA Traditional or PCA Choice.
5. Provide the required 'Provider Agency Information' by entering the agency name, NPI or UMPI, name and title of the requestor, and the agency's phone and fax numbers.
6. In the 'Additional Information' section, include any necessary details related to your request.
7. If you are requesting a new provider, the 'Recipient or Responsible Party' section must be completed. Print the name, signature, relationship to the recipient, and the date the change is requested.
8. After completing all fields and sections, review the information entered for accuracy.
9. Once satisfied with the form, save the changes, and choose to download, print, or share the completed MN 4074A form as needed.

Complete your MN 4074A form online today for an efficient request process.