Get Oltl Service Authorization Form Hcbs Waiver Programs

The OLTL Service Authorization Form for HCBS Waiver Programs is essential for individuals seeking authorization for various services. This guide offers a comprehensive overview and step-by-step instructions to assist users in filling out the form accurately and efficiently online.

Follow the steps to complete the form online effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the date in the designated section, selecting whether this is an annual renewal, new referral, temporary change, or a revision due to a change in need.
3. Fill out the consumer’s name and date of birth in the appropriate fields.
4. Provide the consumer’s address and phone/email for contact purposes.
5. List the primary contact and their relationship to the consumer, followed by their phone/email information.
6. Enter the primary care physician's details, including their phone, fax, and email.
7. Include the ICD-9 diagnosis code and the 10-digit medical assistance number.
8. Indicate if this is a termination request.
9. Specify the provider's name and the program name selected from the list of waiver programs.
10. Detail the specific service authorized by selecting from the approved service list.
11. Input the total number of approved units per week along with the service provision dates.
12. Outline the preferred schedule for service duration and frequency.
13. State the desired outcome of the service to guide the provision.
14. Provide the name and agency of the service coordinator, including their contact information.
15. Detail any special conditions or instructions related to the service.
16. Describe the individualized backup plan for continuity of service.
17. Include any unique circumstances that may affect service, such as allergies, presence of pets, or children living in the home.
18. Finally, review all sections for accuracy, save changes, and then proceed to download, print, or share the completed form as needed.

Take action now and complete your OLTL Service Authorization Form online today.