Forms

Instructions are included with the forms listed below.

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Forms

TitleDescriptionFile SizeFile Type
DHS -4695 Authorization FormUpdated: October 2014307 KB.pdf
DHS 3642 Printable Emergency Medical Assistance CPC request 93 KB.pdf
DHS 3642-EMA CPC Request FormUpdated 11.201660 KB.pdf
DHS 3806A-Instructions for the MHCP: Early Intensive Developmental and Behavioral Intervention (EIDBI) Authorization Request formService providers should use this instructions sheet at they complete the DHS-3806 authorization form for EIDBI services that exceed the service limit threshold (e.g., additional CMDE in a calendar year, additional coordinated care conference in a ca119 KB.pdf
DHS 4315 (DME) Mobility DevicesForm is utilized for the following: K0001-K0009,K0800-K0891,K0898,E1161,E1231-E1239, E1031-E1039, K011-K0014281 KB.pdf
DHS 4370 9DME) Enclosed Medical BedForm is utilized for the following: E1399,E0316,E0328,E0329369 KB.pdf
DHS 4424 EMA Drug Authorization Request FormPosted June 201681 KB.pdf
DHS- 3538 Dental Implants 291 KB.pdf
DHS- 4045 (DME) Specialized Wound TherapyForm is utilized for the following: E2402,E1399,K0743, A4649331 KB.pdf
DHS- 4074 Home Care Technical Change Reqeust Form 535 KB.pdf
DHS- 4075 (DME) Stander and AccessoriesForm is utilized for the following: E0637,E0638,E0641,E0642232 KB.pdf
DHS- 4159 Childrens Therapeutic Services and SupportsForm is utilized for the following: H2012, 90832, 90834, 90837, 90833,90836,90838, 90846-90849, 90853,90875, 90876 H2014, H2019, H2015129 KB.pdf
DHS- 4676 Inpatient Hospital Authorization FormForm is utilized for the following: Inpatient Authorization reqeust200 KB.pdf
DHS- 4879 Vision Therapy 274 KB.pdf
DHS- 6119 (Dental) TMD TreatmentForm is utilized for the following: 41899205 KB.pdf
DHS- 6249 LOCUS Recording FormForm is utilized for the following: H2012, H2017, H0034,90882,H0019, H0040237 KB.pdf
DHS-3806 Early Intensive Developmental and Behavioral Intervention (EIDBI) AuthorizationService providers use this form to request authorization for EIDBI services that exceed the service limit threshold (e.g., additional CMDE in a calendar year, additional coordinated care conference in a calendar year, etc.). Published 5.1.2017227 KB.pdf
DHS-3971 (DME) Enternal/NuturitionalForm is utilized for the following: B4149-B4162223 KB.pdf
DHS-4153 Childrens Day Treatment and Theraputic Services and SupportsForm is utilized for the following: H2012, 90832, 90834, 90837, 90833,90836,90838, 90846-90849, 90853,90875, 90876 H2014, H2019, H2015129 KB.pdf
DHS-4159A Adult Mental Health RehabilitativeForms utilized for the following codes: H2012, H2017, H0034, 90882, and H0019612 KB.pdf
DHS-4437 Prosthetics and OrthoticsForm is utilized for the following: All L Codes211 KB.pdf
DHS-4535 (DME) Augmentative Communication Devices and AccessoriesForm is utilized for the following: E2500-E2599351 KB.pdf
DHS-4878 Chiropractic Authorization FormForm is utilized for the following: 98940-98942236 KB.pdf
DHS-4905C Extended Psychistric Inpatient- Initial Review 226 KB.pdf
DHS-4905D Extended Psychiatric Inpatient- Weekly Bed review 304 KB.pdf
DHS-4905F Extended Psychiatric Inpatient- Discharge Summary Review 227 KB.pdf
DHS-6008 (DME) Bath/Shower/Toileting EquipmentForm is utilized for the following: E0163-E0168, E0170-E0172, E0240, E0244, E0245,E0247-E0248,E0625254 KB.pdf
DHS-6322 Initial Dialectical Behavior TherapyForm is utilized for the following: H2019806 KB.pdf
DHS-6322A Dialectical Behavior TherapyForm is utilized for the following: H2019126 KB.pdf
DHS-6516A- EIDBI Technical Change FormUpon Completion submit Form to DHS354 KB.pdf
DHS-7109D- EIDBI 60 Day Temporary Increase FormUpon Completion upload completed form via the Atrezzo Provider Portal263 KB.pdf
Transportation Level Of Need AssessmentAfter Hours Submission26 KB.docx

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