Cerned MA 325 2/15 CONTROL NUMBER 1150 ADMINISTRATIVE WAIVER REQUEST FORM 2. RECIPIENT NAME: LAST FIRST 1. 3. RECIPIENT NUMBER 4. RES. CODE 5. SOCIAL SECURITY NUMBER - 6. DATE OF BIRTH - 7. ADDRESS ZIP CODE 8A. ITEM/SERVICE REQUESTED M.A.I.D. NUMBER 9A. ITEM/SERVICE REQUESTED M.A.I.D. NUMBER 8B. QUANTITY NUMBER OF MONTHS 9B. QUANTITY NUMBER OF MONTHS 8C. PROVIDER NAME: 9C. PROVIDER NAME: 8D. ADDRESS 9D. ADDRESS TELEPHONE NUMBER TELEPHONE NUMBER 8E. REQUESTED FEE P.
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How to fill out the 1150 Administrative Waiver Request Ma325 online
Filling out the 1150 Administrative Waiver Request Ma325 online is an important task for professionals seeking inpatient hospital services, long-term care, and early intervention. This guide will provide you with clear, step-by-step instructions to help you successfully complete the form.
Follow the steps to fill out the form accurately and efficiently.
- Press the ‘Get Form’ button to access the 1150 Administrative Waiver Request Ma325 form online and open it for editing.
- Begin by completing the recipient information section, including their name, recipient number, residency code, social security number, date of birth, and address.
- In box 8A, enter the name or basic description of the item or service being requested, and specify the quantity needed for a specific time period in box 8B.
- If requesting a second item or service, complete box 9A with the relevant details, including the description and quantity in box 9B.
- Fill in the provider's name, M.A.I.D. number, and address in boxes 8C and 8D. If the prescriber is the provider, skip these fields.
- Provide the requested fee per month in box 8E and the total amount at the bottom of the section.
- Complete the prescriber identifying information in boxes 10, 11, 12, 12A, 12B, 13A, 13B, and 14. Make sure to include the primary diagnosis and corresponding ICD code in box 14.
- If applicable, include any secondary diagnosis information in box 15.
- Attach any necessary medical documentation to support the waiver request, including medical history and diagnostic studies.
- Ensure that the prescriber signs and dates the form. Retain a copy for your records and send the department's copy to the correct address based on the services requested.
Complete the 1150 Administrative Waiver Request Ma325 online today to ensure timely processing of your request.
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