Get Mn Dhs-4159a 2023-2025

The MN DHS-4159A form is essential for requesting authorization for adult rehabilitative mental health services. This guide will provide you with clear, step-by-step instructions to ensure you can effectively complete the form online.

Follow the steps to fill out the MN DHS-4159A online

1. Click the ‘Get Form’ button to obtain the MN DHS-4159A and open it in your editing tool.
2. Fill in the provider information section, including the provider name, NPI or UMPI, contact name, and phone number.
3. Complete the recipient information by entering the recipient's last name, first name, middle initial, date of birth, and MHCP ID number.
4. In the section titled 'Reason for this request', check all applicable boxes to indicate why authorization is needed and provide any required information about concurrent services.
5. List the prior mental health service history for the past 12 months by checking all applicable services and including start and end dates where needed.
6. Detail the ICD-10 diagnosis for the recipient, providing the diagnosis code and description.
7. Attach the required supporting documentation as outlined in the form, ensuring all six items listed are included.
8. Review the completed form for accuracy, ensuring all fields are filled and relevant information is provided.
9. Once completed, you can save your changes, download the form, print it, or share it as necessary.

Take action by completing the MN DHS-4159A online today to ensure the prompt authorization of needed services.