Waiver Specialized Medical Supplies Referral Form

Header

Date of Birth

Insurance ID#

Care Coordinator & PASSE Information

Name

Supervisor Name

Phone #

Supervisor Email

Email

Is this member on the Waiver Waitlist?

Yes No

PCSP Start Date

PCSP End Date

Select One

New Request Renewal Revision

PASSE

AR Total Care Empower CareSource Summit

Clinic / PCP Information

Physician's Name

Clinic Name/City

Clinic Phone

Clinic Fax

Date of Last Appt

Patient Information

First Name

Last Name

Date of Birth

Gender

Male Female

Phone Number

Email

Delivery Address

Diagnoses

Emergency Contact

Name

Relationship to Patient

Email

Phone Number

Insurance Information

Please list ALL active insurances, including Medicare Part C & commercial.

PASSE ID

Medicaid #

Commercial/Other Insurance?

Yes No

Member ID

Group Number

Medicare #

Care Coordinator Agreement

As the care coordinator for this client, I agree that I have spoken to the client regarding these specific medical supplies and quantities. The client has given permission for Finnegan Health Services to provide these services, I will contact Finnegan Health Services if any changes are needed on this order.

CC Name

Date

Signature

Frequently Requested Items / Categories

Please specify item(s) and monthly or yearly quantity needed. Frequency will be determined by minimum shipping requirements. House brand is noted for each category, but there may be other brands/options available upon request.

Notes / Special Requests / Additional Information

CES Waiver Eligibility & Coverage

The Medicaid Home and Community-Based Services (HCBS) waiver program is authorized in §1915(c) of the Social Security Act. The program permits a state to furnish an array of home and community-based services that assist Medicaid beneficiaries to live in the community and avoid institutionalization. Application for 1915(c) HCBS Waiver, Appendix B, Section B-1: Target Group(s). Under the waiver of Section 1902(a)(10)(B) of the Act, the state limits waiver services to one or more groups or subgroups of individuals; these groups include Autism, Developmental Disability, and Intellectual Disability. In accordance with 42 CFR §441.301(b)(1)(ii), waiver services are not furnished to individuals who are in-patients of a hospital, nursing facility or ICF/IID. All items requested on the attached order form must appear in the Participant-Centered Service Plan (PCSP) and be subjected to prior approval by Utilization Management before they can be provided to the participant. Please be aware that updates, revisions, or additions made to an order after it has been submitted to Utilization Management for review can delay the approval process by 6-8 weeks. Please include the medical diagnoses from the PCSP that are applicable to the attached request.

By signing below, I certify that I have met with the Participant and their representatives, and the items/services requested on the attached form meet the requirements listed above and are based on documented medical needs. By signing below, I certify that I have met with the Participant and their representatives and discussed the specific items/quantities requested on the attached form.

Medical diagnoses from the PCSP applicable to this request

I,

I affirm that all the statements above are true and accurate.

Date

Care Coordinator Signature

Referring Source

Referring Source Clinic

Referring Source Name

Referring Source Phone

Referring Source Email or Fax

Waiver Specialized Medical Supplies Referral Form

Header

Care Coordinator & PASSE Information

Clinic / PCP Information

Patient Information

Emergency Contact

Insurance Information

Care Coordinator Agreement

Frequently Requested Items / Categories

Personal Care

Skin Protectant

Bathing Gloves

Body Wash / Soap

Shampoo

Teeth

Wipes - Flushable

Wipes - Adult

Wipes - Baby

Mattress Protectors & Reusable Underpads

Vitamins & Supplements

CES Waiver Eligibility & Coverage

Referring Source