Forms

Instructions are included with the forms listed below.

Forms

Many of Kepro's documents are provided in Adobe Acrobat Reader format.

DHS 3806A-Instructions for the MHCP: Early Intensive Developmental and Behavioral Intervention (EIDBI) Authorization Request form

DHS 3806A-Instructions for the MHCP: Early Intensive Developmental and Behavioral Intervention (EIDBI) Authorization Request form

Description: Service 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)

DHS 4315 (DME) Mobility Devices

DHS 4315 (DME) Mobility Devices

Form is utilized for the following: K0001-K0009,K0800-K0891,K0898,E1161,E1231-E1239, E1031-E1039, K011-K0014

DHS 4370 (DME) Enclosed Medical Bed

DHS 4370 (DME) Enclosed Medical Bed

Form is utilized for the following: E1399,E0316,E0328,E0329

DHS 4424 EMA Drug Authorization Request Form

DHS- 3538 Dental Implants

DHS- 4045 (DME) Specialized Wound Therapy

DHS - 4045 (DME) Specialized Wound Therapy

 

Form is utilized for the following: E2402,E1399,K0743, A4649

DHS- 4074 Home Care Technical Change Request Form

DHS- 4075 (DME) Stander and Accessories

DHS- 4075 (DME) Stander and Accessories

Form is utilized for the following: E0637,E0638,E0641,E0642

DHS- 4159 Children's Therapeutic Services and Supports

DHS- 4159 Children's Therapeutic Services and Supports

Form is utilized for the following: H2012, 90832, 90834, 90837, 90833,90836,90838, 90846-90849, 90853,90875, 90876 H2014, H2019, H2015

DHS- 4676 Inpatient Hospital Authorization Form

DHS- 4676 Inpatient Hospital Authorization Form

Form is utilized for the following: Inpatient Authorization request

DHS- 4879 Vision Therapy

DHS- 6249 LOCUS Recording Form

DHS- 6249 LOCUS Recording Form

Form is utilized for the following: H2012, H2017, H0034,90882,H0019, H0040

DHS-3642 Emergency Medical Assistance - Care Plan Certification Request Form

DHS-3806 Early Intensive Developmental and Behavioral Intervention (EIDBI) Authorization

DHS-3806 Early Intensive Developmental and Behavioral Intervention (EIDBI) Authorization

Service 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 5.1.2017

DHS-3971 (DME) Enternal/Nuturitional

DHS-3971 (DME) Enternal/Nutritional

Form is utilized for the following: B4149-B4162

DHS-4153 Children's Day Treatment and Therapeutic Services and Supports

DHS-4153 Children's Day Treatment and Therapeutic Services and Supports

Form is utilized for the following: H2012, 90832, 90834, 90837, 90833,90836,90838, 90846-90849, 90853,90875, 90876 H2014, H2019, H2015

DHS-4159A Adult Mental Health Rehabilitative

DHS-4159A Adult Mental Health Rehabilitative

Forms utilized for the following codes: H2012, H2017, H0034, 90882, and H0019

DHS-4437 Prosthetics and Orthotics

DHS-4437 Prosthetics and Orthotics

Form is utilized for the following: All L Codes

DHS-4535 (DME) Augmentative Communication Devices and Accessories

DHS-4535 (DME) Augmentative Communication Devices and Accessories

Form is utilized for the following: E2500-E2599

DHS-4695 Prior Authorization Fax Form

DHS-4878 Chiropractic Authorization Form

DHS-4878 Chiropractic Authorization Form

Form is utilized for the following: 98940-98942

DHS-4905C Extended Psychiatric Inpatient- Initial Review

DHS-4905D Extended Psychiatric Inpatient- Weekly Bed review

DHS-4905F Extended Psychiatric Inpatient- Discharge Summary Review

DHS-6008 (DME) Bath/Shower/Toileting Equipment

DHS-6008 (DME) Bath/Shower/Toileting Equipment

Form is utilized for the following: E0163-E0168, E0170-E0172, E0240, E0244, E0245,E0247-E0248,E0625

DHS-6119-ENG TMD Dental Treatment Authorization Form

DHS-6119-ENG TMD Dental Treatment Authorization Form

Use with CPT 41899; Published 12/28/20

DHS-6322 Initial Dialectical Behavior Therapy

DHS-6322 Initial Dialectical Behavior Therapy

Form is utilized for the following: H2019

DHS-6322A Dialectical Behavior Therapy

DHS-6322A Dialectical Behavior Therapy

Form is utilized for the following: H2019

DHS-6516A- EIDBI Technical Change Form

DHS-6516A- EIDBI Technical Change Form

Upon Completion submit Form to DHS

DHS-7109D- EIDBI 60 Day Temporary Increase Form

DHS-7109D- EIDBI 60 Day Temporary Increase Form

Upon Completion upload completed form via the Atrezzo Provider Portal

DHS-7666 Psychiatric Residential Treatment Facility ( PRTF) Individual Plan of Care and Authorization Form

DHS-7696 Psychiatric Residential Treatment Facility ( PRTF) Eligibility for Admission Form

Transportation Level Of Need Assessment

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