Information You Complete

Before sending the DHS-6112 to the client, you must complete the following information:

• The county and worker identification information on pages 1 and 2.
• The date the form is being sent.
• The client’s address.
• Identifying information about the medical expense(s) for the provider, on page 1.
• The provider’s name, patient’s name and date of birth found in the box following the client’s signature on page 2.
• The description of the medical expense(s) in the box on page 2.

Notice the checkbox on page two that is checked when documentation is attached. You may attach a copy of the verification of the medical expense provided to you.