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Get MN DHS-4315-ENG 2011-2024

Orization Request transaction or the Authorization Form (DHS‑4695) to request authorization for a mobility device. Fax this form with any additional or required documentation to the medical review agent. If more space is needed, continue answer on a separate sheet and indicate the question you are answering. If coverage policy requires a PT/OT exam, attach documentation of that exam to this form. Provider Information PROVIDER NAME NPI/UMPI CONTACT NAME PHONE NUMBER ( ) Recipient Informa.

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