Try for free

Minnesota DHS-4315 Mobility Device Authorization

Minnesota Health Care Programs require this four-page form alongside the authorization request when a supplier asks MHCP to cover a wheelchair, power wheelchair or scooter. It walks through the recipient's function, living situation, equipment trials, home access and less costly alternatives. The medical review agent uses it to judge medical necessity, and a physician signs to verify the information.

Who completes it

The equipment specialist, the PT, OT or other professional involved in the evaluation, and the physician verifying the information each sign and date page 4. The provider's details and the manufacturer's pricing documentation go with it.

Submitting and payment

How to submit it
Fax the form with the MN-ITS authorization request or the DHS-4695 Authorization Form, plus any required documentation, to the medical review agent. Attach PT/OT exam documentation when coverage policy requires one.

Good to know

  • A scooter request must explain why a manual wheelchair will not work, a power wheelchair request why a scooter will not, and group 4 or group 3 chairs why the next lower group will not.
  • If the provider has no chair for a trial, DHS pays rental for up to 3 months without authorization, and that rental is deducted from the purchase price unless extenuating circumstances are proven.
  • Options such as power elevating leg rests, tilt, recline, a power seat elevator, nonstandard seat width or depth and attendant control each need their own medical necessity and least costly alternative explanation.
  • Attach the manufacturer's quote, price list or invoice unaltered. If the need is permanent, request purchase, because rental is not appropriate for a permanent wheelchair need.

Get the official form

Download the current version from the source each time; forms change without notice.

Minnesota Health Care Programs (MHCP) Mobility Device Authorization Form

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Who signs the Minnesota DHS-4315?

Page 4 has three signature lines: the equipment specialist, the PT, OT or other professional involved in the evaluation (with credentials), and the physician verifying the information. Each signature is dated. The physician's signature confirms the clinical information the evaluators recorded.

Is DHS-4315 the authorization request itself?

No. DHS-4315 is used in addition to the MN-ITS Authorization Request transaction or the paper Authorization Form, DHS-4695. It supplies the medical necessity detail for a mobility device and is faxed to the medical review agent with the other required documentation.

What does DHS-4315 ask about equipment trials?

It asks for trials of the requested equipment in the recipient's home, school, work and community, with the outcome and an assessment of accessibility, including whether a ramp, stairs or an elevator exist. It also asks how the equipment will be transported and whether it fits the family vehicle.