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- Click ‘Get Form’ to open it in the editor.
- Begin by filling in your 'Name', 'DOB', and 'Sex' legibly. Ensure that all information is accurate to avoid delays.
- The licensed treating physician/evaluator must complete the form. They should type or print legibly, ensuring every question is answered as directed.
- Include the physician's printed/typed name, signature, address, phone number, date of signature, and the applicant’s health plan details along with their Medicaid provider number or NPI.
- Attach any additional medical information that may support the disability evaluation. This can enhance the assessment process.
- Ensure that the applicant or their guardian signs the patient acknowledgment section. If not signed, provide a reason for this omission.
- Complete the 'Official Use Only' section if applicable and return all forms to the specified address or fax number provided in the instructions.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2013 | 4.9 Satisfied (496 Votes) |
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Related links
Applicants with disability DHS 1100, DHS 1128 Health Plan Enrollment. You may reapply at any time.
Aug 8, 2006 Prohibits a physician from making referrals for certain designated health services (DHS) payable by Medicare
Dec 16, 2024 Instructions for Form 1040. Disability pensions shown on Form 1099-R if you havent DocHubed the minimum retirement age set by your employer.