DHS-4695-ENG: Minnesota Health Care Programs (MHCP) Authorization Form

DHS-4695-ENG PDF Details

Place an “X” in the appropriate Authorization Type box.

Change: if you are making a change to an existing authorization, mark the Change for PA # box and print the 11-digit authorization number.

Start date: enter the first date of service (MM/DD/YYYY) for this authorization request.

ID number: enter the recipient's 8-digit MHCP ID number.

Model number: if you are requesting authorization for a medical supply, enter the model number or UPC.

Qty/Units: enter the total number of procedure/service units.