DHS-4159A Adult Mental Health Rehabilitative - kepro mhcp 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Provider Information section. Enter the provider name, NPI/UMPI, contact name, and phone number.
3. Next, complete the Recipient Information section. Input the last name, first name, middle initial, date of birth, and MHCP ID number.
4. In the Reason for this Request section, check all applicable boxes that explain why authorization is needed. Be sure to include any necessary supporting documentation.
5. For Prior Mental Health Service History, check each box that applies for services received in the past 12 months and provide dates where required.
6. Fill out the Recipient Diagnosis section by entering relevant dates for diagnostic assessments and attach necessary documents.
7. Complete the Treatment Plan section by detailing medical necessity for additional units of service and projected discharge criteria.
8. Review all entries for accuracy before submitting your form through our platform.

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