Get Hi Dhs 1144e 2003-2026

The HI DHS 1144E form is essential for requesting medical authorization for EPSDT medically fragile case management, skilled nursing, and personal care services. This guide provides step-by-step instructions to help users fill out the form accurately and efficiently.

Follow the steps to complete the form successfully.

1. Click 'Get Form' button to obtain the form and open it in your online editor.
2. Begin by entering the Medicaid I.D. number in the designated field at the top of the form.
3. Next, provide the patient's name using the format: Last, First, M.I. Alongside this, include the patient's date of birth and gender, ensuring clarity in your entries.
4. Indicate whether the patient has other insurance by checking the appropriate box and, if applicable, providing the name of the insurance company.
5. Fill out the present address of the patient, including street address, city, and zip code. Check the applicable box if the patient resides in a home other than 'Own Home/Family Home'.
6. Sections 1-7 must be completed by a physician. This involves checking yes or no for specific medical conditions and services requested. Fill out each diagnosis and required information thoroughly.
7. Physician certification is required; ensure the physician signs, dates, and provides their printed name, provider number, contact name, telephone number, and fax number if different from the physician.
8. The case management supplier must fill out the relevant codes, quantities per month, and the periods requested, following the guidelines laid out for specific case management requests.
9. Lastly, the skilled nursing/personal care supplier/agency must certify the services requested by signing and dating the submission. They also need to provide their printed name, mailing address, and contact information.
10. After completing the form, save changes, and consider downloading or printing the document for your records. You may also share it with the necessary parties.

Complete your HI DHS 1144E form online today for efficient service authorization.