Home Health Authorization Request
-101652-10973Home Health Authorization Request*Home Health Program ManagerDivision of Healthcare Services – Medical Benefits and Clinical ReviewPO Box 45535 Olympia, WA 98504-5535A typed and completed General Authorization for Information form (HCA 13-835) must be attached to be processed.This is confidential information only intended for the person it is faxed to.To: Home Health Program Manager Fax Number: 1-866-668-1214Contact name FORMTEXT ?????Agency name FORMTEXT ?????Provider NPI FORMTEXT ?????Phone number FORMTEXT ?????Fax number FORMTEXT ?????Clinical contact FORMTEXT ?????Client’s name FORMTEXT ?????ProviderOne client ID FORMTEXT ?????DSHS (social worker or nurse) case manager (if known) FORMTEXT ?????Phone number FORMTEXT ?????Fax number FORMTEXT ?????Type of request FORMCHECKBOX FORMCHECKBOX Limitation extension FORMCHECKBOX Prior authorization required for clients with AEM coverageADDITIONAL THERAPY REQUEST INFORMATION FORMCHECKBOX PT – Number of units requested: FORMTEXT ?????Number of units used this year: FORMTEXT ?????(1 unit = 15 minutes) FORMCHECKBOX OT – Number of units requested: FORMTEXT ?????Number of units used this year: FORMTEXT ?????(1 unit = 15 minutes) FORMCHECKBOX ST – Number of units requested: FORMTEXT ?????Number of units used this year: FORMTEXT ?????(1 unit = 1 visit, no matter the length of the visit)Home Health - related diagnosis(es) FORMTEXT ?????ICD 9 Dx: FORMTEXT ?????Description FORMTEXT ?????ICD 9 Dx: FORMTEXT ?????Description FORMTEXT ?????What is the reason that Home Health is needed, or why does it not meet Home Health program criteria? For clients with AEM coverage, how is this related to the emergency condition? FORMTEXT ?????What is the client-specific medical justification (or reason for this request) and what services will be provided? FORMTEXT ?????For Home Health, why is this client not able to access the skilled care needed in the community? FORMTEXT ?????For Home Health, what is the estimated time that the client will receive services? FORMTEXT ?????*The plan of care (including provider orders) must be attached to this request. ................
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