Loading
Form preview
  • US Legal Forms
  • Form Library
  • More Forms
  • More Multi-State Forms
  • Mt Dphhs Hps-401 2013

Get Mt Dphhs Hps-401 2013-2026

DPHHS Form No. HPS401Designation of Authorized Personal Representative for Health Information Montana Department of Public Health and Human Services P.O. Box 202960, Helena, MT 596202690 The Health.

How it works

  1. Open form

    Open form follow the instructions

  2. Easily sign form

    Easily sign the form with your finger

  3. Share form

    Send filled & signed form or save

How to fill out the MT DPHHS HPS-401 online

The MT DPHHS HPS-401 form is essential for designating an Authorized Personal Representative for managing your health information. This guide will provide user-friendly, step-by-step instructions on how to accurately complete this form online, ensuring you can effectively name a representative while protecting your privacy.

Follow the steps to fill out the MT DPHHS HPS-401 form online.

  1. Press the ‘Get Form’ button to access the form and launch it in your preferred editing tool.
  2. In the designation section, clearly print the name of the individual you wish to designate as your Authorized Personal Representative in the provided space.
  3. Determining the extent of the authority: You will see two options regarding the privileges of your representative. Choose one by checking the appropriate box. The first option grants full access to your health information, while the second limits access to specified functions—if you select the latter, ensure you list the specific functions clearly.
  4. Read and understand the statement provided, which informs you that you can cancel this designation at any time by using the revocation section of the form.
  5. Sign and date the form in the designated areas to confirm your designation of the personal representative.
  6. Review the completed form for accuracy to ensure all information is correct. Once reviewed, you can either save your changes, download the document, print it out, or share it as needed.

Complete your MT DPHHS HPS-401 form online today to ensure your health information is managed according to your preferences.

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.
Get form

Related content

HIPAA - DPHHS - Montana.gov
The Montana Department of Public Health and Human Services (DPHHS) is a “hybrid ... of...
Learn more
NEW PLANS - Salve Regina University
Interested employees must enroll with Gerry Charbonneau at 401-884-0618 or gacharb@cox...
Learn more

Related links form

CA FW-011 S 2009 Notice To Appear For Reconsideration - Courts Ca 2015 CA FW-012 2015 CA FW-012 S 2015

Questions & Answers

Get answers to your most pressing questions about US Legal Forms API.

Contact support

At apply.mt.gov, individuals can also create an online account. An online account allows individuals to update their contact information, renew their coverage when it's time, and receive correspondence. Call the Public Assistance Helpline at 1-888-706-1535.

Toll free at 1-800-346-5437 The CSSD phone system allows individuals to receive general CSSD information, including payment and account balances, as well as the ability to speak to a case worker directly and an option to answer a short customer satisfaction survey.

Montana first enacted this policy for children covered under Medicaid/HMK. Since the start of Medicaid expansion in 2016, Montana's Medicaid program has had a policy of 12-month continuous eligibility for most adults receiving healthcare coverage.

Please contact Provider Relations via email at MTPRhelpdesk@conduent.com or call Provider Relations at (800) 624-3958 if you have questions or concerns.

Under the expanded guidelines, Medicaid is available for all adults with incomes up to 138% of poverty; in 2023, that's $20,120 for a single adult. (Medicaid and CHIP eligibility limits for children and pregnant women are higher, and remained unchanged by the waiver approval.)

Need help finding your local Office of Public Assistance, Enrolled Medicaid Provider, or Passport Provider? Call Montana Healthcare Programs, Member Help Line 1-800-362-8312, M-F, 8am-5pm, for assistance. Find a Montana Medicaid Provider.

Public Health and Human Services General Information (406) 444-5622 111 North Sanders Helena, MT 59601-4520 PO Box 4210 Helena, MT 59604-4210 Department of Public Health and Human Services Organizational ChartFAX Number(406) 444-1970Websitedphhs.mt.govQuick Lookup:172 more rows

For electronic claims, the 160-M can either be faxed to 406.442. 4402 with the appropriate Paperwork Attachment Cover Sheet or mailed with the same cover sheet to Claims, P.O. Box 8000, Helena, MT 59604.

Montana's Medicaid program provides Montanans with low-incomes access to health care benefits and services based on their medical needs and life circumstances. Its Healthy Montana Kids program is the largest provider of health care for children in the state.

Who is eligible for Montana Medicaid? Household Size*Maximum Income Level (Per Year)2$19,7203$24,8604$30,0005$35,1404 more rows

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.
Get form
If you believe that this page should be taken down, please follow our DMCA take down processhere.

Industry-leading security and compliance

US Legal Forms protects your data by complying with industry-specific security standards.
  • In businnes since 1997
    25+ years providing professional legal documents.
  • Accredited business
    Guarantees that a business meets BBB accreditation standards in the US and Canada.
  • Secured by Braintree
    Validated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.
Get MT DPHHS HPS-401
Get form
  • Adoption
  • Bankruptcy
  • Contractors
  • Divorce
  • Home Sales
  • Employment
  • Identity Theft
  • Incorporation
  • Landlord Tenant
  • Living Trust
  • Name Change
  • Personal Planning
  • Small Business
  • Wills & Estates
  • Packages A-Z
  • Affidavits
  • Bankruptcy
  • Bill of Sale
  • Corporate - LLC
  • Divorce
  • Employment
  • Identity Theft
  • Internet Technology
  • Landlord Tenant
  • Living Wills
  • Name Change
  • Power of Attorney
  • Real Estate
  • Small Estates
  • Wills
  • All Forms
  • Forms A-Z
  • Form Library
  • Legal Hub
  • About Us
  • Help Portal
  • Legal Resources
  • Blog
  • Affiliates
  • Contact Us
  • Delete My Account
  • Site Map
  • Industries
  • Forms in Spanish
  • Localized Forms
  • State-specific Forms
  • Forms Kit
  • Real Estate Handbook
  • All Guides
  • Notarize
  • Incorporation services
  • For Consumers
  • For Small Business
  • For Attorneys
  • USLegal
  • FormsPass
  • pdfFiller
  • signNow
  • altaFlow
  • DocHub
  • Instapage
Form Packages
  • Adoption
  • Bankruptcy
  • Contractors
  • Divorce
  • Home Sales
  • Employment
  • Identity Theft
  • Incorporation
  • Landlord Tenant
  • Living Trust
  • Name Change
  • Personal Planning
  • Small Business
  • Wills & Estates
  • Packages A-Z
Form Categories
  • Affidavits
  • Bankruptcy
  • Bill of Sale
  • Corporate - LLC
  • Divorce
  • Employment
  • Identity Theft
  • Internet Technology
  • Landlord Tenant
  • Living Wills
  • Name Change
  • Power of Attorney
  • Real Estate
  • Small Estates
  • Wills
  • All Forms
  • Forms A-Z
  • Form Library
Customer Service
  • Legal Hub
  • About Us
  • Help Portal
  • Legal Resources
  • Blog
  • Affiliates
  • Contact Us
  • Delete My Account
  • Site Map
  • Industries
  • Forms in Spanish
  • Localized Forms
  • State-specific Forms
  • Forms Kit
Legal Guides
  • Real Estate Handbook
  • All Guides
Prepared for you
  • Notarize
  • Incorporation services
Our Customers
  • For Consumers
  • For Small Business
  • For Attorneys
Our Sites
  • USLegal
  • FormsPass
  • pdfFiller
  • signNow
  • altaFlow
  • DocHub
  • Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
© Copyright 1999-2026 airSlate Legal Forms, Inc. 3720 Flowood Dr, Flowood, Mississippi 39232
  • Your Privacy Choices
  • Terms of Service
  • Privacy Notice
  • Content Takedown Policy
  • Bug Bounty Program