Forms

DHS-4878 Chiropractic Authorization Form

Form is utilized for the following: 98940-98942 - Posted 11.23.22

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

Description: Service providers should use this instructions sheet as they complete the DHS-3806 authorization form for EIDBI services that exceed the service limit threshold (e.g., additional CMDE in a calendar year). - Posted 11/23/22

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.).  -Posted 11.23.22

DHS- 3538 Dental Implants

-Posted 11/23/22

DHS-6119-ENG TMD Dental Treatment Authorization Form

Use with CPT 41899; Posted 11.23.22

DHS 4315 (DME) Mobility Devices

Form is utilized for the following: K0001-K0009,K0800-K0891,K0898,E1161,E1231-E1239, E1031-E1039, K011-K0014. Posted - 11/23/22

DHS 4370 (DME) Enclosed Medical Bed

Form is utilized for the following: E1399,E0316,E0328,E0329. Posted 11/23/22

DHS - 4045 (DME) Specialized Wound Therapy

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

-Posted 11/23/22

DHS- 4075 (DME) Stander and Accessories

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

-Posted 11/23/22

DHS-3971 (DME) Enternal/Nutritional

Form is utilized for the following: B4149-B4162 - Posted 11.23.22

DHS-4437 Prosthetics and Orthotics

Form is utilized for the following: All L Codes - Posted 11.23.22

DHS-4535 (DME) Augmentative Communication Devices and Accessories

Form is utilized for the following: E2500-E2599. -Posted 11.22.23

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

Form is utilized for the following: E0163-E0168, E0170-E0172, E0240, E0244, E0245, E0247-E0248, E0625. -Posted 11.22.23

DHS 4424 EMA Drug Authorization Request Form

-Posted 11/23/22

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

-Posted 11.23.22

DHS- 4074 Home Care Technical Change Request Form

-Posted 11/23/22

DHS- 4676 Inpatient Hospital Authorization Form

Form is utilized for the following: Inpatient Authorization request - Posted 11/23/22

DHS 4159 (CTSS) Children's Therapeutic Services and Supports Authorization Form

-Posted 2.23.23

DHS-4159A Adult Mental Health Rehabilitative

Forms utilized for the following codes: H2012, H2017, H0034, 90882, and H0019.  Posted 10.19.23

DHS 4695 Prior Authorization Fax Form 

DHS-4905C Extended Psychiatric Inpatient- Initial Review

DHS-4905D Extended Psychiatric Inpatient- Weekly Bed review

DHS-4905F Extended Psychiatric Inpatient- Discharge Summary Review -

DHS-6322 Initial Dialectical Behavior Therapy

Form is utilized for the following: H2019 - Posted 11.22.23

DHS-6322A Dialectical Behavior Therapy

Form is utilized for the following: H2019. -Posted 11.23.22

SUD Authorization Questionnaire (Fillable PDF)

-Posted 3/15/2024

Transportation Level Of Need Assessment

After Hours Submission

DHS- 4879 Vision Therapy

-Posted 11/23/22

Oral Surgery Questionnaire

-Posted 1/27/2023

Orthodontia Questionnaire

-Posted 01/11/2021

Dental D1110 Prophylaxis Questionnaire

-Updated 03/13/2023

Periodontal Therapy Checklist

- Posted 7/19/2022