Drc4371 Form PDF Details

Drc4371 is a form that is used to collect demographic and health information from beneficiaries. The form can also be used to identify individuals who need additional assistance with their health care needs. Drc4371 is used by providers, managed care organizations, and others who are responsible for providing or arranging for the provision of health care services. The form helps ensure that individuals receive the right health care services. Completed forms should be submitted to the local Medicaid agency in order to obtain reimbursement for services provided.

QuestionAnswer
Form NameDrc4371 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesannually, notarized, updated, minor authorization form drc 4371

Form Preview Example

Ohio Department of Rehabilitation and Correction

AuthorizationForMinorChildVisitation

I certify that I am the Legal Guardian of:

Child’s Name

Child’s Name

Child’s Name

Child’s Name

I am giving permission for the following list of people to bring the above named child/children to the

to visit inmate:

Name of Institution

Inmate Name:

Number:

1.

2.

3.

4.

5.

Name

Address/City/State/Zip

Relationship To Child

I hereby give my permission for the child/children listed above to be searched by employees of the

.

Name of Institution

I understand that the child/children may only visit with the people I have listed and I have enclosed a copy of the child/children’s birth certificate and or custody papers. This document must be notarized prior to submis- sion.Any changes, additions or deletions require the completion of a new form. This form must be updated annually from the date of receipt.

Parent/Guardian Name (Printed):

Date:

Parent/Guardian Signature:

Telephone Number:

()

NOTARY STAMP

Notary Signature

DRC4371(REV. 10/06)

How to Edit Drc4371 Form Online for Free

Using the online editor for PDFs by FormsPal, it is possible to fill in or alter notarized here and now. Our editor is continually developing to provide the best user experience attainable, and that's because of our commitment to constant enhancement and listening closely to customer opinions. It just takes a few basic steps:

Step 1: Just hit the "Get Form Button" in the top section of this page to launch our form editing tool. Here you will find all that is needed to fill out your file.

Step 2: As soon as you open the editor, you will find the form prepared to be completed. Besides filling in various blank fields, you might also do other sorts of things with the PDF, particularly writing your own textual content, editing the original textual content, adding graphics, placing your signature to the form, and much more.

It is simple to fill out the document following this detailed tutorial! This is what you must do:

1. The notarized requires specific information to be entered. Make sure the subsequent blanks are completed:

Step number 1 for completing completion

2. Immediately after this section is completed, go to type in the applicable details in all these - I hereby give my permission for, Name of Institution, I understand that the, ParentGuardian Name Printed, Date, ParentGuardian Signature, Telephone Number, Notary Signature, and NOTARY STAMP.

Notary Signature, NOTARY STAMP, and Date inside completion

People generally make mistakes when completing Notary Signature in this part. Be certain to reread everything you type in here.

Step 3: Check that the details are correct and simply click "Done" to complete the process. After starting afree trial account with us, you will be able to download notarized or send it through email promptly. The PDF will also be readily available via your personal account page with your each edit. Here at FormsPal, we endeavor to be sure that your information is stored private.

Drc4371 Form isn’t the one you’re looking for?

Related Documents