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Get MN DHS-6322A-ENG 2012-2024

322) for definition and eligibility criteria. ASSIGNED NUMBER FROM MN–ITS EXISTING PRIOR AUTHORIZATION NUMBER Complete this form if DBT treatment is currently in progress to request authorization for continued DBT services. The conclusion of the summary determines a recipient is likely to benefit from continued DBT treatment and that progress is being made toward discharge or a lower level of care. Enter all dates in MM/DD/YYYY format. Recipient Information RECIPIENT LAST NAME DATE OF CURR.

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