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Dhs 1147 instructions-2026
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- Click ‘Get Form’ to open the DHS Form 1147 in the editor.
- Begin by checking the appropriate box for the evaluation type: initial, annual, reconsideration, or other review.
- Enter the patient's name and birthdate in the designated fields. Ensure accuracy as this information is crucial.
- Indicate the patient's gender by selecting 'M' for male or 'F' for female.
- For Medicare eligibility, check the relevant boxes and input the Medicare I.D. number if applicable.
- Specify Medicaid eligibility by selecting 'Yes' or 'No', and provide the Medicaid I.D. number if available.
- Fill in the present address of the patient, choosing from options like Home, Hospital, Nursing Facility, etc.
- Complete sections regarding attending physician details and return form contact information accurately.
- For referral information, complete all sections if it’s an initial request; skip if it’s an annual review.
- Finally, ensure all assessment information is filled out correctly before submitting your form electronically through our platform.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2014 | 5 Satisfied (31 Votes) |
What is the form 1147?
DHS 1147 Form - Functional Status related to Health Conditions: Sections III XII are scored. These sections primarily provide information about the individuals functional status as related to his/her health conditions.
What is an 1147 form?
The DHS Form 1147 is designed to assess a patients Level of Care and At Risk evaluation effectively. It serves as a comprehensive tool for healthcare providers to document patient information essential for determining eligibility for various services.
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