Follow the steps to accurately complete the DHS 1144E Form online.

1. Press the ‘Get Form’ button to access the DHS 1144E Form and open it for online completion.
2. Complete the Recipient Information section with the patient's Medicaid ID number, name, date of birth, and gender. Indicate the present and mailing addresses, and if applicable, provide the name of any other health care insurer.
3. Fill out the Physician Information section by answering yes or no to questions regarding ventilator dependence and tracheostomy. Ensure to provide specific details about the patient's medical conditions if they fall under other diagnoses.
4. Confirm the requested services by marking yes or no for hourly skilled nursing and personal care, and enter how many hours per day are needed. Attach the completed EPSDT Home Skilled Nursing Scoring Tool if applicable.
5. Verify if medically fragile case management services are needed by marking the appropriate box and attaching the completed EPSDT Medically Fragile Case Management Scoring Tool.
6. Ensure the physician signs and dates the form, confirming that the patient is under their care and the services requested are medically necessary.
7. Complete the Supplier Information section by circling the necessary code(s) and entering the quantity needed per month. Both suppliers for case management and skilled nursing/personal care must sign to certify the information provided.
8. Provide additional contact information for both the physician and suppliers, including telephone and fax numbers for any follow-up required by the Medicaid Consultant.
9. Once completed, ensure all sections are filled accurately. Save changes, download, print, or share the completed form as needed.

Begin your application by completing the DHS 1144E Form online today.