Get Hi Dhs 1144b 2013-2025

This guide provides clear and detailed instructions for successfully completing the HI DHS 1144B form online. Whether you are familiar with online forms or are a first-time user, these steps will help ensure that you complete the process efficiently and effectively.

Follow the steps to fill out the HI DHS 1144B form online.

1. Click the ‘Get Form’ button to access the HI DHS 1144B form online.
2. Complete the request type by selecting only one option: either 'Home Infusion PA' or 'Non-home infusion (Medication only) PA'. Ensure only one box is checked.
3. In section 1, enter the Medicaid ID number carefully to avoid any errors.
4. Fill in the Recipient’s Name in section 2 using the format Last, First, Middle Initial.
5. Indicate whether the recipient has Medicare coverage in section 5. Select 'Yes' or 'No' as applicable.
6. In section 6, specify the current location of the recipient by checking the appropriate box: Home, Hospital, or various facility options.
7. Provide the recipient’s Mailing Address in section 7, including Street, City, and Zip Code.
8. In the Physician Section, provide the necessary medication or service details, including NDC Number or Drug Name, Strength, Units, and codes as required.
9. Enter the quantity in section 10, ensuring that all necessary fields are filled accurately.
10. Fill in the Gender and Date of Birth in section 4, selecting M or F for gender.
11. Indicate whether the recipient is undergoing Expanded EPSDT in section 7.
12. Proceed to the Supplier Section to fill out the Rent/Repair request in section 11. Circle the appropriate option and indicate the period requested.
13. Provide the Purchase Price along with all relevant medical information in the specified sections.
14. In sections 14 to 20, include the necessary diagnosis or ICD-9 code, justification for the request, and the prescriber's details.
15. Ensure the Prescriber’s Signature, NPI, contact telephone number, and fax number are completed in sections 19 to 23.
16. Fill in the Supplier Section thoroughly by providing the Supplier's Name, contact details, and signature in the relevant sections.
17. Review all entries for accuracy and completeness; check that each required field is filled in before proceeding.
18. After final reviews, you can save your changes, download the form, print it, or share it as needed.

Complete and submit your HI DHS 1144B form online today to ensure efficient processing of your medical authorization request.