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INSTRUCTIONS DHS 1139D (04 08) ACUTE HOSPITAL ATTACHMENT PURPOSE: Form DHS 1139D shall be used by he

INSTRUCTIONS DHS 1139D (04 08) ACUTE HOSPITAL ATTACHMENT PURPOSE: Form DHS 1139D shall be used by he 2026

INSTRUCTIONS DHS 1139D (04 08) ACUTE HOSPITAL ATTACHMENT PURPOSE: Form DHS 1139D shall be used by he Preview on Page 1

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The document outlines the purpose and instructions for completing Form DHS 1139D, which is required by health care facilities providing acute inpatient hospital services. It must be submitted alongside the DHS 1139 Medicaid Application/Change Request Form.

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Click ‘Get Form’ to open it in the editor.
In the first field, enter the 'Print Name of Provider'. This should be the name of the health care facility providing acute inpatient hospital services.
Next, locate the 'Signature' field. Here, you will need to sign your name to validate the form.
Finally, find the 'Date Signed' field and input the date on which you are signing this form. Ensure that this date is accurate as it may be important for processing.

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