Get Medicaid Fa11a

The Medicaid Fa11a is an essential document for users seeking authorization for rehabilitation services. This comprehensive guide provides clear, step-by-step instructions on how to fill out the form online, ensuring that you understand each section and requirement.

Follow the steps to complete the Medicaid Fa11a form online.

1. Click 'Get Form' button to obtain the Medicaid Fa11a and open it in your editor. This will allow you to access the form for completion.
2. Begin by entering the request date and the recipient's name in the designated fields. This information is critical for processing your request efficiently.
3. Specify the request type by selecting from the available options, which include Initial Prior Authorization, Concurrent Authorization, Unscheduled Revision, Reconsideration, and Retrospective Authorization. Provide additional details like the start date of services, if applicable.
4. Complete the coordinating QMHP section by filling in the name, credentials, and NPI of the qualified mental health professional, along with their contact information.
5. In the requesting provider's section, input the name, credentials, NPI, and contact details of the provider who is requesting the authorization.
6. Fill in the recipient's details, including date of birth, recipient ID, age, and living arrangements. Check if the recipient is in State custody and provide relevant dates if applicable.
7. Provide the responsible party's information, including name, relationship to the recipient, phone number, and address.
8. In the multiaxial diagnosis section, document the DSM diagnosis across the required axes, including primary, secondary, and tertiary codes and narratives.
9. List the symptoms and significant life events that relate to the recipient's Axis I diagnosis, ensuring to provide detailed information.
10. Outline the treatment plan and rationale for each identified problem or behavior, including goals and progress during the last authorized period.
11. Detail the current medications being taken, including names and dosages. Attach additional sheets if necessary for complete documentation.
12. Describe previous and current treatment efforts for psychiatric and pertinent medical conditions.
13. Complete the requested treatment section with all relevant codes, units per day, and specify start and end dates.
14. Finalize and review all provided information before submitting the form. Users can save changes, download, print, or share the completed form.

Take the next step in securing services by completing the Medicaid Fa11a form online today.