Oral enteral nutrition expedited prior authorization (EPA ...
Thickeners for Children from 1 – 20 years old
Expedited Prior Authorization (EPA) Form
To be completed by the vendor and the prescribing provider.
Must be available in client record for audit purposes for 6 years (WAC 182-502-0020).
|CLIENT INFORMATION |
|Client name |Provider one client ID |
| | |
|Date of birth |Age in weeks |Gestational age if preterm |
| | | |
|Does this child have a diagnosis of dysphagia confirmed by videofluoscopy? Yes No |Applicable ICD-10 Dx code: |
| | |
|PROVIDER INFORMATION |
|Prescribing provider |NPI |Telephone number |
| | | |
|PCP |NPI |Telephone number |
| | | |
|GI provider (if applicable) |Telephone number |
| | |
|Speech therapist /occupational therapist |Telephone number |
| | |
|Date and findings of most recent videofluoroscopic swallow study documenting dysphagia. What thickener was used in the study and why? |
|DIETITIAN INFORMATION |
|Name of registered dietitian |Telephone number |
| | |
|Dietitian consult and dysphagia diet assessment and recommendations must be attached. WAC 182-554-525(1)(b) requires RD assessment and a dysphagia diet plan, |
|including an assessment of adequacy of nutrient intake (energy, protein, vitamin and minerals). Be sure to include details on the contribution to the total diet|
|made by thickener (for instance, amount of indigestible CHO- fiber, gum, based on composition of product). |
|SERVICE REQUEST INFORMATION |
|Product name |HCPCS code |HCPCS units per day |
| | | |
|VENDOR INFORMATION |
|Vendor name |Provider NPI |
| | |
|Vendor contact person |Contact’s direct phone number |Vendor fax number |
| | | |
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