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Instructions care developmentally disabled individuals 2026

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The document outlines the purpose and instructions for the DHS 1139F form, which is used by health care facilities providing intermediate care services for developmentally or intellectually disabled individuals. It must be submitted alongside the DHS 1139 Medicaid Application/Change Request Form and includes sections for provider information, facility name, signature, and date.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the 'Print Name of Provider/Authorized Business Agent' in the designated field. This should be the name of the individual or entity responsible for submitting the form.
Next, fill in the 'Name of Health Care Facility'. Ensure that this is accurate and matches any official documentation.
Proceed to provide the 'Signature of Provider/Authorized Business Agent'. This confirms that all information provided is true and accurate.
Finally, enter the 'Date Signed' in the appropriate field. This date should reflect when you completed and signed the form.

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