Dhs 3642-2026

1. Click ‘Get Form’ to open the DHS-3642 in the editor.
2. Begin by filling in the 'Assigned Authorization Number' and 'Requested Start Date' at the top of the form. Ensure these fields are accurate to avoid delays.
3. Complete the 'Recipient Information' section, including last name, first name, MHCP recipient ID, birthdate, address, and phone number. All fields must be filled out completely.
4. In the 'Provider Information' section, enter your details such as provider name, NPI, contact information, and fax number. This ensures proper communication regarding your request.
5. If applicable, provide details for the guardian or responsible party. This is crucial for cases where a recipient has a designated guardian.
6. Fill in the ICD-10 Diagnosis Code and description accurately. Only include emergency medical diagnoses relevant to this request.
7. Describe the plan of care thoroughly. Include treatment services that are critical for maintaining health and preventing deterioration.
8. Check all applicable medical documentation required for processing your request in the 'Medical Information Required' section.
9. Finally, ensure you sign and date the form in the 'Physician or Dentist Information' section before submitting it via fax.

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