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REFERRAL LICENSED INDEPENDENT PRACTITIONER SERVICES (LIPS)ONLY TO BE USED BY THE PHYSICIAN FOR SERVICES NOT REQUIRED TONE LISTED ON THE INDIVIDUAL PLAN OF CAREBeneficiary Name: ___ Beneficiary Medicaid
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01
Obtain a copy of the DHS-4695-ENG MHCP Authorization form.
02
Fill in all required fields, including patient's personal information, provider information, and authorization details.
03
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04
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05
Submit the completed form to the appropriate department or agency as instructed.

Who needs dhs-4695-eng mhcp authorization form?

01
Patients who are seeking authorization for Medical Assistance through the Minnesota Health Care Programs (MHCP) may need to fill out the DHS-4695-ENG MHCP Authorization form.

What is DHS-4695-ENG (MHCP Authorization ) Form?

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The DHS-4695-ENG MHCP Authorization Form is a document used to authorize the release of health care information related to the Minnesota Health Care Program.
Individuals who are seeking to have their medical information shared for the purposes of receiving services under the Minnesota Health Care Program are required to file the DHS-4695-ENG MHCP Authorization Form.
To fill out the DHS-4695-ENG MHCP Authorization Form, you need to provide personal identification information, specify the type of information being authorized for release, and sign the form to grant permission.
The purpose of the DHS-4695-ENG MHCP Authorization Form is to obtain consent from individuals to share their health information, ensuring compliance with privacy laws while facilitating access to necessary medical services.
The information that must be reported on the DHS-4695-ENG MHCP Authorization Form includes the individual's name, date of birth, specific health information to be shared, and the signature of the individual authorizing the release.
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