Get Dhs 1147 Instructions 2014-2025

Filling out the DHS 1147 form online can simplify the process of submitting essential information for level of care and at-risk evaluation. This guide will walk you through each section of the form, ensuring you understand how to accurately complete it.

Follow the steps to successfully complete the DHS 1147 form.

1. Click ‘Get Form’ button to acquire the DHS 1147 form and launch it in your editing environment.
2. Check the appropriate box to indicate the type of evaluation request: initial, annual, reconsideration, or other review. This establishes the purpose of your submission.
3. Enter the patient’s full name in the designated field, ensuring correct spelling.
4. Fill in the patient’s birth date, using the appropriate format, to verify their age.
5. Indicate the patient’s gender by selecting ‘M’ for male or ‘F’ for female.
6. Mark the checkbox demonstrating whether the patient is enrolled in Medicare and provide their Medicare I.D. number if applicable.
7. Select ‘Yes’ or ‘No’ to indicate if the patient is currently Medicaid eligible, and provide their Medicaid I.D. number or state ‘pending’ with the application date if they have applied but are not yet deemed eligible.
8. Provide the patient’s current address, detailing the location such as home, hospital, or nursing facility.
9. If applicable, enter the Medicaid provider number; this is only needed if the patient is pending Medicaid and not in a managed care plan.
10. Please fill in the name and contact details of the attending physician or primary care provider, including telephone and fax numbers.
11. Indicate where to return the completed form by entering the name of the service coordinator or relevant contact, along with their contact details including email.
12. For initial requests, complete the referral information, including all relevant sections. Skip this for annual or other reviews.
13. Identify the source of the information provided and the person responsible for the patient's decisions, including their contact information.
14. Provide the primary language spoken at home and indicate if ‘Other.’
15. Fill in the assessment information, including date and the assessor’s details, ensuring the assessor signs the form.
16. Specify what is being requested (level of care or at risk), including the start and end date, and attach any necessary hospice documentation if applicable.
17. Do not fill out the Medical Necessity Determination section as this is for DHS reviewers only.
18. Complete patient background information by providing their name, birthdate, and health functional status.
19. Provide detailed accounts of the patient’s medical conditions and medications, and explain their functional status if needed.
20. Finally, ensure the form is saved for your records before downloading, printing, or sharing it as necessary.

Complete your DHS 1147 form online today to ensure a smooth submission process!