Dhs-54-A, Medical Needs State Of Michigan Department Of Human Services
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1Case Name
MEDICAL NEEDS
State of Michigan
Case Number
Recipient ID Number
Department of Human Services
Patient’s Name
Patient’s Birth Date
INSTRUCTIONS: To be completed annually by a physician,
nurse practitioner, physical or occupation therapist. Please
County
District
Section
Unit
Specialist
print or type.
Specialist
Specialist Phone Number
(
)
Medical Provider:
We would appreciate your cooperation in
completing the spaces checked below. In
addition to a physician, Box A may be
completed by a physician’s assistant,
certified nurse-midwife, ob-gyn nurse
practitioner or ob-gyn clinical nurse
specialist. Providers must be Medicaid
enrolled. An addressed, prepaid envelope is
enclosed for your convenience.
You are hereby authorized to release the information requested below to the Department of Human Services.
Patient’s or Representative’s Signature
Patient’s Name
Signature Date
Authorized Specialist’s Signature
Signature Date
Local DHS Office
Pregnancy Delivery (Expected) Date
Number of medically verified unborn children
A
Diagnosis(es) / Treatment plan for this patient
B
C
Chronic ongoing illness
YES
NO
Estimated number of office or clinic visits
Will this
YES, When
D
____________ times per
week
month
quarter
Other (Please Specify)
change?
(Date)
NO
Give estimated number of months for the diagnosis in B that medical treatment will be required
E
Lifetime
Is the patient non-ambulatory?
If Yes, explain:
F
YES
NO
Does patient need special transportation? If Yes, indicate mode of transportation needed (e.g., van with wheelchair lift, ambulance, etc.)
G
YES
NO
Does someone need to accompany the patient to the medical appointment?
If yes, who / why?
H
YES
NO
Do you certify the patient has a medical need for assistance with any
Check any complex care services needed.
of the personal care activities listed below?
Specialized Feeding
Suctioning
YES
NO
I
Eating
Dressing
Meal Preparation
Catheters or Leg Bags
Bedsore Prevention
Toileting
Transferring
Shopping
Colostomy Care
Range of Motion
Bathing
Mobility
Laundry
Bowel Program
Other _______________________
Grooming
Taking Medications
Housework
Can patient work at usual occupation?
YES
YES, but with limitations (Specify below)
NO (How long):
Can Patient work at any job?
YES
YES, but with limitations (Specify below)
NO (How long):
J
Other (Explain)
K
Is the spouse or parent of the above disabled individual?
L
Yes
No (Needed in the home to provide care)
Yes
No (Cannot engage in work due to the extent of care required.)
Date patient was last seen
Are you a Medicaid enrolled provider?
YES
NO
Name and title (Print or type)
MA enrolled Provider Signature
National Provider Identifier (NPI) Number
Signature Date
Telephone Number
Department of Human Services (DHS) will not discriminate against any individual or
AUTHORITY: Federal 45 CFR of 233.20, CFR 440.10 and CFR 440.20
group because of race, religion, age, national origin, color, height, weight, marital
COMPLETION: Voluntary
status, sex, sexual orientation, gender identity or expression, political beliefs or
disability. If you need help with reading, writing, hearing, etc., under the Americans with
PENALTY: Benefits may be affected.
Disabilities Act, you are invited to make your needs known to a DHS office in your area.
DHS-54A (Rev. 10-08) Previous edition may be used. MS Word
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