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.

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

Signature of Service Coordinator _________________________________

Office Location _________________ Phone ___________ Date ________

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

Posted January 25th, 2008