Dhb 3051 Form - Fill Out and Sign Printable PDF Template-2025

1. Click ‘Get Form’ to open the Dhb 3051 Form in our editor.
2. Begin with Section A, where you will enter the beneficiary’s demographics. Ensure the name matches their Medicaid card and provide the necessary contact information.
3. In Section B, detail the beneficiary’s medical conditions that necessitate assistance with Activities of Daily Living (ADLs). Include both the diagnosis and corresponding ICD-10 codes.
4. Proceed to Section C to input practitioner information. This includes signing and dating the form, ensuring no signature stamps are used.
5. If applicable, complete Sections D and E for medical change requests or managed care disenrollment. Provide detailed descriptions of changes impacting care needs.
6. For non-medical changes or provider requests, fill out Sections F and G on page 3, detailing any changes in condition or provider preferences.
7. Once all sections are completed, submit your form via fax as indicated at the bottom of the document.

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