CLIENT PLACEMENT AUTHORIZATION CPA - CCDTF DHS-2780-ENG 6-08 - hennepinhealth-2026

1. Click ‘Get Form’ to open the CLIENT PLACEMENT AUTHORIZATION form in the editor.
2. Begin by entering the 'AGREEMENT START DATE' and 'AGREEMENT END DATE' in the designated fields. Ensure the dates are formatted correctly.
3. Fill in your 'PMI# (RECIP ID)' and 'CLIENT NAME' (Last Name, First Name, MI). If applicable, include any client alias.
4. Provide the 'DOB' (Date of Birth), 'County of Residence', and 'Co/Tribe of Financial Responsibility'.
5. Complete additional fields such as language preference, marital status, gender, and social security number as required.
6. Review sections for service details including service agreement numbers, procedure codes, and financial responsibility information.
7. Finally, ensure all signatures are obtained where necessary before submitting the form for processing.

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