Get Dshs 13 720
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How to fill out the Dshs 13 720 online
Filling out the Dshs 13 720 form correctly is crucial for obtaining authorization for treatment. This guide provides a step-by-step approach to ensure that all necessary information is submitted accurately and efficiently.
Follow the steps to complete your Dshs 13 720 form online.
- Click ‘Get Form’ button to obtain the Dshs 13 720 document and open it for editing.
- Complete the Chemical Dependency Treatment Agency section by entering the name of the DBHR certified chemical dependency treatment agency and their 8-digit agency number from the Directory of Certified Chemical Dependency Services in Washington State.
- Fill in the Patient section with the patient’s name, birthdate, and Medicaid ProviderOne number. Make sure to have the patient sign the authorization for the disclosure of confidential information.
- In the Physician section, enter the physician's name, telephone number, and address. Input the DEA ID number and verify the compliance with criteria. Have the physician sign and date the form.
- Complete the Pharmacy section by providing the pharmacy name, NPI number, contact numbers, and address. Ensure these details are accurate for reimbursement purposes.
- Once all sections are filled out, ensure that you review the form for accuracy. Save your changes, and prepare to fax the completed form to DBHR at 360-725-2279 for authorization.
Complete your Dshs 13 720 form online to facilitate the authorization process for treatment.
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Applying for Washington DSHS benefits is a straightforward process that can be done online, by mail, or in person at local DSHS offices. Start by gathering necessary documents, such as proof of income and identification. The DSHS 13 720 application guides you through each step of the process, ensuring you provide all required information. To enhance your application experience, visit the US Legal Forms platform for helpful resources and downloadable forms.
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