Dhs 54A Form PDF Details

The DHS 54A form is a document used by U.S. Customs and Border Protection (CBP) to collect information from non-U.S. citizens traveling into the United States. The form is also used to determine whether a traveler is eligible for admission into the country. completion of the DHS 54A form is required for all travelers, regardless of nationality or citizenship status. In this blog post, we will explore what information is collected on the DHS 54A form, and how it can be used to facilitate your travel experience.

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

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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

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