Dhs 1503-2026

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4.9 out of 5

44 votes

The document DHS-1503-ENG is a Physician Certification form used for long-term care (LTC) admissions. It requires detailed information about the provider, recipient, admission details, and physician's certification of the need for long-term care services. The form must be completed within 72 hours of admission and includes sections for diagnoses, screening information, and signatures from both the physician and local county agency. It ensures compliance with state and federal regulations regarding medical assistance.

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Click ‘Get Form’ to open the DHS 1503 in the editor.
Begin by filling in the PROVIDER INFORMATION section. Enter the LTC Provider’s Name, phone number, and address. Include the NPI and any reference numbers as needed.
In the RECIPIENT INFORMATION section, input the recipient's name, Medical Assistance Number, gender, and birthdate. Make sure to provide the anticipated discharge date.
For diagnosis details, specify both primary and secondary diagnoses along with their respective DIAG codes.
Complete the PREADMISSION SCREENING section by indicating whether a screening was done prior to admission and providing relevant details if applicable.
Fill out ADMISSION INFORMATION by selecting the recommended level of care and length of stay. Ensure all boxes are checked appropriately based on the recipient's situation.
Finally, have the physician sign and date where indicated. Ensure that all required fields are completed before submitting.

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Versions	Form popularity	Fillable & printable
2017	4.9 Satisfied (44 Votes)
2008	4.1 Satisfied (75 Votes)

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