Get Mi Dch-1074 2015-2025
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How to fill out the MI DCH-1074 online
The MI DCH-1074 form, also known as the Hospice Membership Notice, is essential for hospice agencies to communicate crucial information regarding hospice enrollment, disenrollment, and updates to the Michigan Department of Health and Human Services. This guide provides step-by-step instructions on how to successfully complete the form online, ensuring that users have a clear understanding of each section and field.
Follow the steps to fill out the MI DCH-1074 with ease.
- Press the ‘Get Form’ button to acquire the MI DCH-1074 form and open it for editing.
- Identify the purpose of the form by checking the appropriate box for Enrollment Application, Enrollment Update, or Disenrollment Notice at the top right corner.
- Provide the effective date corresponding to the action selected in step 2. This date needs to be mutually agreed upon.
- In Section I, fill in the hospice provider’s name, national provider ID, hospice provider ID, control number, address, phone number, and fax number.
- Enter the attending physician’s name and address, including their national provider ID number.
- Indicate if the beneficiary is a Waiver participant by selecting 'Yes' or 'No'.
- Proceed to Section II if the beneficiary currently resides in a Nursing Facility or Ventilator Dependent Care Unit. If not, skip to Section III.
- In Section II, enter the facility name, address, provider ID number, national provider ID, and date the beneficiary was admitted.
- In Section III, complete the beneficiary information, including their name, ID number, address, social security number, birth date, gender, and home phone number.
- Determine if the beneficiary is enrolled in the Children’s Special Healthcare Services program and indicate 'Yes' or 'No'.
- Provide any necessary information regarding previous hospice enrollment, estimated remaining life span, and any diagnosis codes.
- Utilize Section IV for any additional remarks or explanations related to the beneficiary’s situation or needs.
- In Section V, ensure that the beneficiary or their authorized representative certifies understanding of the Conditions of Enrollment by checking the appropriate box and signing it.
- Final signatures are required in Section V, including the enrollee or representative’s signature and dates, as well as a witness signature if applicable.
- Once all sections are completed accurately, users can save changes, download, or print the form for submission.
Complete the MI DCH-1074 online to ensure timely processing of hospice services.
To file a complaint against a nursing home in Michigan, contact the Michigan Department of Health and Human Services (MDHHS) directly. The MI DCH-1074 form is essential for properly documenting your concerns. Make sure to provide detailed information regarding your complaint, as this helps facilitate a more thorough investigation. You can file the complaint online, through the mail, or by phone, ensuring your concerns are heard.
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