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Get MN DHS-4159A 2023-2024

T rehabilitative mental health services (ARMHS), Day Treatment or intensive residential treatment services (IRTS). See instructions for completing this form on page 3. Provider information PROVIDER NAME NPI or UMPI CONTACT NAME PHONE NUMBER Recipient information LAST NAME FIRST NAME MI DATE OF BIRTH MHCP ID NUMBER Reason for this request (check all that apply) This service requires authorization before being provided This service requires authorization because of concurrent care Name o.

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