Get Mn Dhs-4695-eng 2014-2025

Navigating the MN DHS-4695-ENG form can be streamlined with clear guidance. This form is crucial for authorizing services in Minnesota Health Care Programs. This guide will provide step-by-step instructions to assist you in completing the form efficiently online.

Follow the steps to successfully complete the MN DHS-4695-ENG form online.

1. Click the ‘Get Form’ button to obtain the MN DHS-4695-ENG form and open it in the editor.
2. In the requestor information section, enter the requestor name, phone number, and check the appropriate affiliation box for pharmacy or prescriber.
3. For authorization information, indicate the type of authorization and provide the start and end dates in MM/DD/YYYY format.
4. Input the necessary pay-to provider information, including name, address, city, state, zip code, phone number, fax number, and NPI/UMPI.
5. Complete the recipient information, which requires the last name, first name, middle initial, ID number, and date of birth.
6. Fill out the service line information, including procedure codes, modifiers, diagnosis codes, rate/charge, quantity/units, model number, and service description/comments.
7. If applicable, include additional service line information on separate pages for more than two services or line items.
8. Sign and date the form to verify the information provided.
9. Once the form is filled out, you can save your changes, download, print, or share the completed document as needed.

Complete the MN DHS-4695-ENG form online to ensure proper authorization of services.