Dhs 54A Form PDF Details

The Dhs 54A form plays a crucial role within Michigan's health and social services, offering a structured method for assessing and documenting the medical needs of individuals under the care of the Michigan Department of Health and Human Services (MDHHS). This comprehensive form is designed to be completed annually by health professionals such as physicians, nurse practitioners, and therapists. It covers a wide range of information, from the patient's identification details to their medical diagnosis, treatment plans, and any special transportation or personal care services they might require. The form's design facilitates seamless communication between healthcare providers and the MDHHS, ensuring that patients receive the appropriate support and services. Its sections address various aspects of patient care, including the need for special transportation, the requirement for someone to accompany the patient to medical appointments, and whether the patient is able to work or requires someone at home for care. Furthermore, it underlines the process of medical verification and emphasizes the role of accredited medical professionals in providing accurate and detailed information. By mandating the completion of the form by Medicaid-enrolled providers and enclosing a prepaid envelope for its return, the MDHHS underscores the importance of streamlined, efficient processing in addressing the medical needs of Michigan's residents.

QuestionAnswer
Form NameDhs 54A Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesdhs medical needs, dhs forms 54a, dhs 54a, michigan medical needs form

Form Preview Example

MEDICAL NEEDS

Michigan Department of Health and Human Services

INSTRUCTIONS: To be completed annually by a physician, nurse practitioner, physical or occupation therapist. Please print or type.

Case Name

Case Number

 

 

Recipient ID Number

 

 

 

 

 

 

 

 

 

Patient’s Name

 

 

 

 

 

Patient’s Birth Date

 

 

 

 

 

 

 

 

 

County

 

District

Section

 

Unit

 

Specialist

 

 

 

 

 

 

 

Specialist

 

 

Specialist Phone Number

 

 

 

 

(

)

 

 

Medical Provider:

We would appreciate your cooperation in completing the spaces checked below. In addition to a physician, Box A may be completed by a physician’s assistant, certified nurse-midwife, ob-gyn nurse practitioner or ob-gyn clinical nurse specialist. Providers must be Medicaid enrolled. An addressed, prepaid envelope is enclosed for your convenience.

You are hereby authorized to release the information requested below to the Michigan Department of Health and Human Services.

Patient’s or Representative’s Signature

 

 

 

Patient’s Name

 

 

 

 

Signature Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Authorized Specialist’s Signature

 

 

 

 

Signature Date

 

Local MDHHS Office

 

 

 

 

 

 

 

 

 

 

 

 

 

A

Pregnancy Delivery (Expected) Date

 

 

Number of medically verified unborn children

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B

Diagnosis(es) / Treatment plan for this patient

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C

Chronic ongoing illness

 

YES

NO

 

 

 

 

 

 

 

 

 

 

D

Estimated number of office or clinic visits

 

 

 

 

 

 

 

Will this

YES, When

____________ times per

week

month

quarter

Other (Please Specify)

change?

NO

 

(Date)

 

 

 

 

 

 

 

 

 

 

 

 

E

Give estimated number of months for the diagnosis in B that medical treatment will be required

Lifetime

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F

Is the patient non-ambulatory?

 

 

 

If Yes, explain:

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

G

Does patient need special transportation? If Yes, indicate mode of transportation needed (e.g., van with wheelchair lift, ambulance, etc.)

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

H

Does someone need to accompany the patient to the medical appointment?

 

If yes, who / why?

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you certify the patient has a medical need for assistance with any

Check any complex care services needed.

 

 

 

of the personal care activities listed below?

 

 

 

 

 

 

 

 

 

 

 

 

 

I

 

 

YES

NO

 

 

Specialized Feeding

 

 

 

Suctioning

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Eating

Dressing

 

Meal Preparation

 

 

Catheters or Leg Bags

 

 

 

Bedsore Prevention

 

Toileting

Transferring

 

Shopping

 

 

Colostomy Care

 

 

 

 

Range of Motion

 

 

 

Bathing

Mobility

 

Laundry

 

 

 

 

 

 

 

 

 

 

 

 

Bowel Program

 

 

 

 

Other _______________________

 

Grooming

Taking Medications

Housework

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

J

Can patient work at usual occupation?

YES

YES, but with limitations (Specify below)

NO (How long):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Can Patient work at any job?

 

YES

YES, but with limitations (Specify below)

NO (How long):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (Explain)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

K

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

L

Is the spouse or parent of the above disabled individual needed in the home to provide care?

YES

NO

 

 

 

Spouse or parent cannot engage in work due to the extent of care required.

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

How long:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date patient was last seen

 

 

 

 

 

Are you a Medicaid enrolled provider?

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

Name and title (Print or type)

 

 

 

 

 

MA enrolled Provider Signature

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

National Provider Identifier (NPI) Number

 

 

 

Signature Date

 

 

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

AUTHORITY: Federal 45 CFR of 233.20, CFR 440.10 and CFR 440.20

 

The Michigan Department of Health and Human Services (MDHHS) does not

 

discriminate against any individual or group because of race, religion, age, national

COMPLETION: Voluntary

 

 

 

 

 

origin, color, height, weight, marital status, genetic information, sex, sexual orientation,

PENALTY: Benefits may be affected.

 

 

 

gender identity or expression, political beliefs or disability.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DHS-54A (Rev. 6-15) Previous edition may be used. MS Word

How to Edit Dhs 54A Form Online for Free

When working in the online PDF editor by FormsPal, you're able to complete or modify michigan 54a right here. In order to make our editor better and less complicated to utilize, we continuously design new features, with our users' suggestions in mind. With some basic steps, you may begin your PDF editing:

Step 1: Access the PDF file inside our tool by pressing the "Get Form Button" at the top of this webpage.

Step 2: This tool will allow you to work with your PDF in a variety of ways. Transform it with any text, correct original content, and include a signature - all doable within a few minutes!

This PDF doc will require specific details; in order to guarantee correctness, be sure to take into account the next guidelines:

1. The michigan 54a requires specific information to be entered. Be sure that the following blank fields are finalized:

michigan medical needs form writing process explained (stage 1)

2. After completing the previous section, head on to the next step and fill out all required details in these blanks - Authorized Specialists Signature, Pregnancy Delivery Expected Date, Diagnosises Treatment plan for, C Chronic ongoing illness YES, Signature Date, Local MDHHS Office, Number of medically verified, Estimated number of office or, Will this, times per, week, month, quarter, Other Please Specify, and change.

Writing section 2 of michigan medical needs form

3. Throughout this stage, examine Eating Toileting Bathing Grooming, Is the spouse or parent of the, YES, YES, Date patient was last seen, Name and title Print or type, National Provider Identifier NPI, AUTHORITY Federal CFR of CFR, DHSA Rev Previous edition may be, Are you a Medicaid enrolled, YES, MA enrolled Provider Signature, Signature Date, Telephone Number, and The Michigan Department of Health. All these will need to be filled out with utmost accuracy.

A way to fill in michigan medical needs form stage 3

People generally make some mistakes while completing Eating Toileting Bathing Grooming in this part. You need to re-examine everything you enter right here.

Step 3: Spell-check what you've entered into the form fields and click the "Done" button. After starting a7-day free trial account with us, you will be able to download michigan 54a or send it via email directly. The PDF form will also be available through your personal account with your each edit. We don't sell or share any details that you provide whenever working with documents at our website.

Dhs 54A Form isn’t the one you’re looking for?

Related Documents