Form DHS-4633-ENG "Home Health Certification and Plan of Care" - Minnesota

What Is Form DHS-4633-ENG?

This is a legal form that was released by the Minnesota Department of Human Services - a government authority operating within Minnesota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2008;
  • The latest edition provided by the Minnesota Department of Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DHS-4633-ENG by clicking the link below or browse more documents and templates provided by the Minnesota Department of Human Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form DHS-4633-ENG "Home Health Certification and Plan of Care" - Minnesota

Download PDF

Fill PDF online

Rate (4.8 / 5) 66 votes
Clear Form
*DHS-4633-ENG*
DHS-4633-ENG
5-08
Home Health Certification and Plan of Care
1. SUBSCRIBER ID (all 8 digits required) 2. START OF CARE DATE
3. CERTIFICATION PERIOD
4. PATIENT ACCT. NUMBER
5. NPI/UMPI
FROM:
TO:
6. PATIENT’S NAME AND ADDRESS
7. PROVIDER’S NAME, ADDRESS AND PHONE NUMBER
8. DATE OF BIRTH
9. SEX
10. MEDICATIONS (Dose/Frequency/Route (N)ew (C)hanged)
M
F
11. ICD CODE
PRINCIPAL DIAGNOSIS
DATE
12. ICD CODE
SURGICAL PROCEDURE
DATE
13. ICD CODE
OTHER PERTINENT DIAGNOSES
DATE
14. DME AND SUPPLIES
15. SAFETY MEASURES
16. NUTRITIONAL REQ.
17. ALLERGIES
18A. FUNCTIONAL LIMITATIONS
18B. ACTIVITIES PERMITTED
1
Amputation
5
Paralysis
9
Legally Blind
1
Complete Bedrest
6
Partial Weight Bearing
B
Walker
2
Bowel/Bladder (Incontinence)
6
Endurance
A
Dyspnea with
2
Bedrest BRP
7
Independent At Home
C
No Restrictions
Minimal Exertion
3
Contracture
7
Ambulation
3
Up As Tolerated
8
Crutches
D
Other (specify)
B
Other (specify)
4
Hearing
8
Speech
4
Transfer Bed/Chair
9
Cane
5
Exercises Prescribed
A
Wheelchair
COMMENTS
19. MENTAL STATUS
1
Oriented
2
Comatose
3
Forgetful
4
Depressed
5
Disoriented
6
Lethargic
7
Agitated
8
Other
20. PROGNOSIS
1
Poor
2
Guarded
3
Fair
4
Good
5
Excellent
21A. ORDERS FOR DISCIPLINE AND TREATMENTS (Specify Amount/Frequency/Duration) 21B. PATIENT SUMMARY
22. GOALS/REHABILITATION POTENTIAL/DISCHARGE PLANS
23. NURSE’S SIGNATURE AND DATE OF VERBAL SOC WHERE APPLICABLE
24. DATE HHA RECEIVED SIGNED POT
25. PHYSICIAN’S NAME AND ADDRESS
The patient is under my care, and I have authorized the services on this
26.
plan of care and will periodically review the plan.
X
ATTENDING PHYSICIAN’S SIGNATURE AND DATE SIGNED
Anyone who misrepresents, falsifies, or conceals essential information required for payment of Federal funds may be
subject to fine, imprisonment, or civil penalty under applicable Federal laws.
Clear Form
*DHS-4633-ENG*
DHS-4633-ENG
5-08
Home Health Certification and Plan of Care
1. SUBSCRIBER ID (all 8 digits required) 2. START OF CARE DATE
3. CERTIFICATION PERIOD
4. PATIENT ACCT. NUMBER
5. NPI/UMPI
FROM:
TO:
6. PATIENT’S NAME AND ADDRESS
7. PROVIDER’S NAME, ADDRESS AND PHONE NUMBER
8. DATE OF BIRTH
9. SEX
10. MEDICATIONS (Dose/Frequency/Route (N)ew (C)hanged)
M
F
11. ICD CODE
PRINCIPAL DIAGNOSIS
DATE
12. ICD CODE
SURGICAL PROCEDURE
DATE
13. ICD CODE
OTHER PERTINENT DIAGNOSES
DATE
14. DME AND SUPPLIES
15. SAFETY MEASURES
16. NUTRITIONAL REQ.
17. ALLERGIES
18A. FUNCTIONAL LIMITATIONS
18B. ACTIVITIES PERMITTED
1
Amputation
5
Paralysis
9
Legally Blind
1
Complete Bedrest
6
Partial Weight Bearing
B
Walker
2
Bowel/Bladder (Incontinence)
6
Endurance
A
Dyspnea with
2
Bedrest BRP
7
Independent At Home
C
No Restrictions
Minimal Exertion
3
Contracture
7
Ambulation
3
Up As Tolerated
8
Crutches
D
Other (specify)
B
Other (specify)
4
Hearing
8
Speech
4
Transfer Bed/Chair
9
Cane
5
Exercises Prescribed
A
Wheelchair
COMMENTS
19. MENTAL STATUS
1
Oriented
2
Comatose
3
Forgetful
4
Depressed
5
Disoriented
6
Lethargic
7
Agitated
8
Other
20. PROGNOSIS
1
Poor
2
Guarded
3
Fair
4
Good
5
Excellent
21A. ORDERS FOR DISCIPLINE AND TREATMENTS (Specify Amount/Frequency/Duration) 21B. PATIENT SUMMARY
22. GOALS/REHABILITATION POTENTIAL/DISCHARGE PLANS
23. NURSE’S SIGNATURE AND DATE OF VERBAL SOC WHERE APPLICABLE
24. DATE HHA RECEIVED SIGNED POT
25. PHYSICIAN’S NAME AND ADDRESS
The patient is under my care, and I have authorized the services on this
26.
plan of care and will periodically review the plan.
X
ATTENDING PHYSICIAN’S SIGNATURE AND DATE SIGNED
Anyone who misrepresents, falsifies, or conceals essential information required for payment of Federal funds may be
subject to fine, imprisonment, or civil penalty under applicable Federal laws.