Follow the steps to complete the DHS 1144A form online

1. Click ‘Get Form’ button to access the DHS 1144A form and open it in the editor.
2. In the Patient Information section, have the Physician or Provider enter the patient's Medicaid identification number, name, date of birth (in mm/dd/yy format), and gender. Ensure the present address and mailing address are checked and filled out correctly.
3. In the Physician/Provider Information section, list specific diagnoses causing incontinence. Indicate whether the patient requires diapers, underpads, and gloves by checking 'Yes' or 'No,' and provide the quantity required per month if applicable.
4. Check if additional justification is attached. The Physician/Provider must sign and date the form, then print or stamp their name and provider number.
5. Include the contact name, telephone number, and fax number for the Physician/Provider, ensuring it is correct for follow-up by the Medicaid Consultant.
6. In the Supplier Information section, the supplier should print or stamp their name and supplier number. They must also provide the contact name, telephone number, and fax number needed for additional communication.
7. The Supplier or an authorized representative must sign and date the form. Include the quantity per month for items requested and the period for which supplies are needed—note any supply provided prior to approval in the comments section.
8. Finally, once all sections are filled out, save changes, download, print, or share the completed form as necessary.

Complete your DHS 1144A form online today to ensure a smooth authorization process for incontinence supplies.