Get Form 18 - Request Icd 10 Code - Final Versiondoc - Dspd Utah

Filling out the Form 18 - Request ICD 10 Code allows diagnosing professionals to submit essential information to the Division of Services for People with Disabilities (DSPD) regarding eligibility for services. This guide provides clear, step-by-step instructions to assist users in completing this form accurately online.

Follow the steps to fill out the Form 18 online.

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. In the form, begin by entering the name of the diagnosing professional in the designated field. Ensure this information is accurate as it identifies the person submitting the request.
3. Next, provide the professional's credentials by checking the appropriate box for either Licensed Psychologist, MD, or DO. This information is essential to verify the qualifications of the professional completing the form.
4. Fill in the address and telephone number fields with the professional's contact information. This allows the DSPD to reach out if additional information is needed.
5. In the ‘To’ section, confirm the address for the Division of Services for People with Disabilities. Ensure that it reads: Attn: Intake Unit, 475 West Price River Drive #262, Price, UT 84501-2858.
6. Proceed to the section regarding the patient. Enter the patient's name and date of birth (DOB) in the specified fields. This information helps the DSPD identify the individual for whom the request is submitted.
7. In the response section, write a brief statement indicating your review of the patient's medical documentation, noting the specific ICD-10 Code and Diagnosis that applies.
8. If there are additional ICD-10 codes and diagnoses that apply to the patient, list them in the subsequent fields provided, ensuring each code is matched with its respective diagnosis.
9. Sign the document in the designated space and enter today's date to validate the request.
10. Finally, review the completed form for accuracy, then save your changes. You may download, print, or share the form as necessary to submit to DSPD.

Complete your Form 18 online today to assist individuals in accessing necessary services.