Doh 4359 Doh Form Printable DOH 4359 2010 PHYSICIAN S ORDER FOR PERSONAL CARE CONSUMER DIRECTED PERSONAL ASSISTANCE SERVICES COMPLETE ALL ITEMS INCOMPLETE FORMS WILL BE RETURNED TO THE PHYSICIAN 1 Patient Identifying Information Use Additional Paper If Necessary PATIENT NAME CIN DATE OF BIRTH SEX ADDRESS APT STREET
Physician s Name License Address Telephone Enter information for the physician signing the order Enter either the physician s license number as issued by the New York State Department of Education or the provider billing number issued by the New York State Department of Health Medicaid Management Information System Form DOH 4359 Physician s Order for Personal Care Consumer Directed Personal Assistance Services is a document that can be used by individuals who would like to apply for certain types of assistance such as home care help with skilled or personal tasks housekeeping etc
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FAX THE COMPLETED FORM TO 718 907 3377 If you have any questions call 718 736 2344 and ask to speak with our Intake Department TIPS ON HOW TO ACCURATELY COMPLETE THE DOH 4359 PHYSICIAN S ORDER FOR CONSUMER DIRECTED PERSONAL ASSISTANCE SERVICES 1 The client s name address telephone DOB and CIN number MUST be provided PG 1 2 Suffolk County currently uses the DOH 4359 form confirmed on 9 2016 Westchester County Medical Recommendation for Personal Care Services Form 1050 Rev 10 15 Helping a doctor to complete the medical request form can be tricky because many forms use terms that are not universally understood by doctors
DOH 4359 2010 PHYSICIAN S ORDER FOR PERSONAL CARE CONSUMER DIRECTED PERSONAL ASSISTANCE SERVICES COMPLETE ALL ITEMS I Patient Identifying Information CIN CITY IF CURRENTLY HOSPITALIZED Name of Hospital IF NO EXPLAIN LICENSE CITY INCOMPLETE FORMS WILL BE RETURNED TO THE PHYSICIAN Use Additional Paper If Necessary PATIENT NAME Follow the simple instructions below Experience all the key benefits of completing and submitting forms on the internet Using our service filling in NY DOH 4359 requires just a matter of minutes
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All forms are printable and downloadable DOH 4359 2010 PHYSICIANS ORDER FOR PERSONAL CARE CONSUMER DIRECTED On average this form takes 26 minutes to complete The DOH 4359 2010 PHYSICIANS ORDER FOR PERSONAL CARE CONSUMER DIRECTED form is 2 pages long and contains 1 signature 2 check boxes 100 other fields 01 Edit your doh form online Type text add images blackout confidential details add comments highlights and more 02 Sign it in a few clicks Draw your signature type it upload its image or use your mobile device as a signature pad 03 Share your form with others Send doh 4359 form via email link or fax
View download and print fillable Doh 4359 2010 Physician s Order For Personal Care consumer Directed Personal Assistance Services in PDF format online Browse 243 U s Department Of Health And Human Services Forms And Templates collected for any of your needs Open form follow the instructions Easily sign the form with your finger Send filled signed form or save What makes the doh 4359 form legally valid Completing a pile of papers is still a necessary evil in today s modern world and doh4359 is not an exception
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DOH 4359 2010 PHYSICIAN S ORDER FOR PERSONAL CARE CONSUMER DIRECTED PERSONAL ASSISTANCE SERVICES COMPLETE ALL ITEMS INCOMPLETE FORMS WILL BE RETURNED TO THE PHYSICIAN 1 Patient Identifying Information Use Additional Paper If Necessary PATIENT NAME CIN DATE OF BIRTH SEX ADDRESS APT STREET
https://www.nycdpap.com/pdf/1-DOH-Physicians-Order-for-Personal-Care-Form.pdf
Physician s Name License Address Telephone Enter information for the physician signing the order Enter either the physician s license number as issued by the New York State Department of Education or the provider billing number issued by the New York State Department of Health Medicaid Management Information System
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Doh 4359 Form Printable
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Doh 4359 Doh Form Printable - Follow the simple instructions below Experience all the key benefits of completing and submitting forms on the internet Using our service filling in NY DOH 4359 requires just a matter of minutes
