Minnesota Health Care Programs (MHCP) uses DHS-4695 as the paper authorization request for fee-for-service medical services, medical equipment and supplies, and physician-administered drugs when the MN-ITS authorization transaction is not used. Physicians, therapists, DME suppliers and pharmacies meet it when a service needs MHCP approval or an existing authorization needs changing. Each service line gives codes, dates, rate and units.
The requesting provider completes one form per recipient: requestor, authorization type, pay-to provider, the recipient's 8-digit MHCP ID, ordering or referring provider, and each service line, then signs and dates it.
Download the current version from the source each time; forms change without notice.
MHCP Authorization Form
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.
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Minnesota's eDocs page notes that the fillable PDF will not open in a browser. Download it and open it in Adobe Reader or Acrobat; the downloaded file is named form.pdf. A print-only version is also offered for completing the form by hand.
The form directs supporting documentation for most medical services and equipment and supplies to Acentra, and requests for physician-administered drugs (J-codes) to Prime Therapeutics. Providers can instead submit through the MN-ITS Authorization Request transaction. The current version is dated 6-25.