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MN DHS-4159A 2023-2026 free printable template

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DHS4159AENG523MINNESOTA HEALTH CARE PROGRAMS (MHCP)Adult Mental Health Rehabilitative Services Authorization FormASSIGNED NUMBER FROM MNITSUse this form to request authorization for adult rehabilitative
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Obtain the MN DHS-4159A form from the Minnesota Department of Human Services website or your local office.
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Read the instructions carefully before filling out the form.
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Provide your full name and contact information in the designated fields.
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Fill in your Social Security number and date of birth as required.
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Sign and date the form at the designated section.

Who needs MN DHS-4159A?

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Individuals applying for financial assistance programs in Minnesota.
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Households needing to report changes in their income or family status.
03
Clients of social services programs that require updated information.
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MN DHS-4159A is a form used in Minnesota for reporting certain data related to health and human services.
Individuals and organizations that provide health and human services in Minnesota are required to file MN DHS-4159A if they meet specific reporting criteria.
To fill out MN DHS-4159A, you need to provide accurate and complete information about the services provided, the populations served, and any other required data as specified in the form instructions.
The purpose of MN DHS-4159A is to collect data that helps the Minnesota Department of Human Services evaluate and improve health and human services programs.
Information that must be reported on MN DHS-4159A includes service utilization statistics, demographic information of clients, and other quantitative and qualitative data relevant to the services provided.
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