H: DHHS Prior Authorization for Assisted Living Waiver Service (MC-9AD)


This authorization is void if client is ineligible for Medicaid.
To be completed by Service Coordinator
Client Name: _______________________________
Medicaid ___________________
Number:
Facility Name ____________________

Address ________________________

________________________________
Facility ___________________
Provider
Number:

Level
 
License No.
2801 MD
Diagnosis Code:
V719
Service Begin Date
 
Service End Date
 
(If applicable)
Waiver Payment Effective Date
 
complete even if it is the same as service begin date


Comments:

Check here if this is to amend an existing authorization for this client in this assisted living facility. If so, indicate change here, and forward copies to DHHS Central Office, the assisted living facility, and to the Medicaid eligibility worker.
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Signature of Service Coordinator _________________________________

Office Location _________________ Phone ___________ Date ________



MC-9AD Rev. 3/98 (37010)

 

H