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- Click ‘Get Form’ to open the 3871b document in the editor.
- Begin with Part A, entering the requested eligibility date and admission date. Select the appropriate service type by checking one of the options provided.
- In Part B, fill in the client’s name, current address, and contact information. Ensure all details are accurate for proper identification.
- Proceed to Part C and answer the questions regarding mental health status. Check 'Yes' or 'No' as applicable, providing additional details where necessary.
- Complete Parts D through G by detailing diagnoses, skilled services required, functional assessments, and certifications. Make sure to sign and date where indicated.
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