Get the free Discharge CHW) Authorization Request Form (MSHO only)

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BLUE PLUS / LESS OF MN REFERRAL FORM LESS PostDischarge Community Companion/Meals Service ** CARE COORDINATOR: Complete first page and return to LESS ** Email: communitycompanion@lssmn.org or FAX#

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How to fill out discharge chw authorization request

01

Obtain the discharge Community Health Worker (CHW) authorization request form from the appropriate department or agency.

02

Fill out the patient or client's personal information accurately, including name, date of birth, address, and contact information.

03

Provide details about the CHW services received and the reason for discharge.

04

Include the signature of the healthcare provider or case manager overseeing the patient's care.

05

Submit the completed authorization request form to the designated department or agency for processing.

Who needs discharge chw authorization request?

01

Patients or clients who have received services from a Community Health Worker (CHW) and are being discharged from their care.

02

Healthcare providers or case managers overseeing the care of patients receiving CHW services.

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What is discharge chw authorization request?

Discharge CHW authorization request is a form that allows a community health worker to be discharged from their responsibilities or authorization.

Who is required to file discharge chw authorization request?

A community health worker is required to file a discharge CHW authorization request.

How to fill out discharge chw authorization request?

To fill out a discharge CHW authorization request, the CHW must provide their personal details, reason for discharge, and any supporting documentation.

What is the purpose of discharge chw authorization request?

The purpose of a discharge CHW authorization request is to officially request to be discharged from one's role as a community health worker.

What information must be reported on discharge chw authorization request?

The discharge CHW authorization request must include the CHW's personal information, reason for discharge, and any relevant attachments.

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