Hild Welfare staff) Child/Youth Name Date of Birth Medicaid ID # MiSACWIS Person ID # Legal Status Current Placement Date Placement Type Authorized Consenter(s) Relationship to Child/ Youth Contact Phone Caseworker Caseworker Phone Agency SECTION B HEALTH INFORMATION (Completed by medical provider or medical staff) Physician Name Phone Appointment Date Location of Appointment Witnessed Verbal Consent Identification Number (Completed by PMOU) Mental Health Diagnoses SECTION C.
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How to fill out the MI DHS-1643 online
The MI DHS-1643 form is essential for obtaining informed consent for psychotropic medication for children in foster care and juvenile justice. This guide offers a detailed, step-by-step approach to filling out the form online, ensuring clarity and support throughout the process.
Follow the steps to successfully complete the MI DHS-1643 form.
- Click the ‘Get Form’ button to access the MI DHS-1643 form and open it in the designated editor.
- Begin by filling out Section A, which requires identifying information. This section should be completed by child welfare staff and includes fields such as the child's name, date of birth, Medicaid ID number, MiSACWIS person ID number, legal status, current placement date, placement type, authorized consenters, and their relationships to the child.
- Move on to Section C, which addresses medication recommendations. This is to be completed by the physician or medical staff. You will indicate the medication name, starting (current) dose, maximum dose, and any medications that have been discontinued. Ensure that the physician's signature and date are included at the end of this section.
- Fill out Section D, consent, which must be completed by the consenting party listed in Section A. The consent statement includes the medications’ details, a summary of the physician’s discussion with the consent provider, and space for the consenter's signature, printed name, and date.
- For Section E, youth attestation, if the youth is unable to attest, there is a checkbox for the physician to mark and initial. The youth needs to provide their signature and date if able.
- Finally, once you have filled in all the required sections, you can save your changes, download, print, or share the MI DHS-1643 form as needed.
Complete the MI DHS-1643 form online today for efficient document processing.
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What is informed consent for psychotropic medication?
Informed consent is the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a treatment. The patient must be competent to make a voluntary decision about the treatment. Written informed consent is required for the use of psychotropic medications.
How do I report changes to DHS in Michigan?
Using the Change Report Form You may use the DHS-2240, Change Report Form, to report changes to your specialist. If you choose this method you must answer all questions on the form for everyone in your household. If any questions do not apply to your household situation, answer the question N/A, not applicable.
How can I talk to a real person at Michigan Secretary of State?
Call the Secretary of State Information Center with questions about your driver's license, state ID, vehicle registration or license plate at (888) 767-6424.
How do I speak to someone at DHS Michigan?
Michigan Department of Health & Human Services 517-335-8951 (phone) 517-335-8835 (fax) 1-800-942-1636 (toll-free) 517-335-8951 (voc)
What is the phone number for the Michigan MDHHS provider?
You can contact Provider Support at any point if you need help by phone 1-800-979-4662 or email providersupport@Michigan.gov. 4. How do I get an Adult Service Worker? Call the local Department of Health and Human Services county office and ask for the Adult Services Unit.
How do I talk to a live agent with EBT in Michigan?
1-888-678-8914 This number is also located on the back of your Michigan WIC Bridge Card. You can call this number, free of charge, 24 hours a day, 7 days a week.
How do I find out who is my caseworker at DHS Michigan?
You can find your caseworker's specialist ID on the top right corner of a notice you received from the Michigan Department of Health and Human Services (MDHHS). The specialist ID is usually a combination of the specialist's name.
How do I contact a DHS worker in Michigan?
If you can't reach your worker directly, you can try contacting your local MDHHS office . You can also try calling the main MDHHS phone line at (517) 241-3740. If you are using the MI Bridges website to apply for or manage benefits, you can try calling the MI Bridges help desk at (844) 799-9876.
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