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How to use or fill out CLIENT PLACEMENT AUTHORIZATION CPA - CCDTF DHS-2780-ENG 6-08 - hennepinhealth with our platform
- Click ‘Get Form’ to open the CLIENT PLACEMENT AUTHORIZATION form in the editor.
- Begin by entering the 'AGREEMENT START DATE' and 'AGREEMENT END DATE' in the designated fields. Ensure the dates are formatted correctly.
- Fill in your 'PMI# (RECIP ID)' and 'CLIENT NAME' (Last Name, First Name, MI). If applicable, include any client alias.
- Provide the 'DOB' (Date of Birth), 'County of Residence', and 'Co/Tribe of Financial Responsibility'.
- Complete additional fields such as language preference, marital status, gender, and social security number as required.
- Review sections for service details including service agreement numbers, procedure codes, and financial responsibility information.
- Finally, ensure all signatures are obtained where necessary before submitting the form for processing.
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