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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 Long-Term Care (LTC) provider’s name, phone number, and address. Include the physician's NPI and today's date.
In the Recipient Information section, input the recipient's name, Medical Assistance number, birthdate, and sex. Mark if applying for MA and provide 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. If yes, provide the date and agency name; if no, select an appropriate reason.
Fill out Admission Information by entering dates of first admission and anticipated discharge. Select the recommended level of care and length of stay.
Finally, ensure that the physician signs and dates the form in the designated area before submitting it to your local county agency.

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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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