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Form DHS-4695-ENG Mhcp Authorization Form - Minnesota
What Is Form DHS-4695-ENG?
This is a legal form that was released by the Minnesota Department of Human Services - a government authority operating within Minnesota. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is Form DHS-4695-ENG?
A: Form DHS-4695-ENG is the MHCP Authorization Form used in Minnesota.
Q: What is MHCP?
A: MHCP stands for Minnesota Health Care Programs, which are state-administered Medicaid programs that provide health care coverage for eligible individuals and families.
Q: What is the purpose of Form DHS-4695-ENG?
A: The purpose of Form DHS-4695-ENG is to authorize the Minnesota Health Care Programs to release and exchange medical information for the purpose of determining eligibility and coordinating care.
Q: Who is required to fill out Form DHS-4695-ENG?
A: The person seeking or being provided with health care services through the Minnesota Health Care Programs is required to fill out Form DHS-4695-ENG.
Q: Is Form DHS-4695-ENG specific to Minnesota?
A: Yes, Form DHS-4695-ENG is specific to Minnesota and is used for the MHCP administered by the state.
Q: Are there any fees associated with filling out Form DHS-4695-ENG?
A: No, there are no fees associated with filling out Form DHS-4695-ENG.
Q: How long is Form DHS-4695-ENG valid?
A: The authorization provided on Form DHS-4695-ENG is valid for up to six years from the date of the signature.
Form Details:
- Released on January 1, 2019;
- The latest edition provided by the Minnesota Department of Human Services;
- Easy to use and ready to print;
- Quick to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a fillable version of Form DHS-4695-ENG by clicking the link below or browse more documents and templates provided by the Minnesota Department of Human Services.
Download Form DHS-4695-ENG Mhcp Authorization Form - Minnesota
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