Get Prescription Order Form Dc

The Prescription Order Form Dc is an essential document used to authorize Medicaid-funded long-term care services and supports in the District of Columbia. This guide will provide clear, step-by-step instructions for filling out the form online to ensure accurate and efficient submission.

Follow the steps to complete the Prescription Order Form Dc online

1. Click ‘Get Form’ button to access the Prescription Order Form Dc and open it in your preferred online editor.
2. In Section I: Patient Information, fill in the patient's DC Medicaid number. If the patient is new to DC Medicaid and does not yet have a number, enter 'N/A'.
3. Provide the patient's full name in the format: Last name, First name.
4. Enter the patient's date of birth using the format MM/DD/YYYY.
5. Fill in the patient's primary telephone number and an optional secondary telephone number.
6. Input the patient's current address and, if applicable, the permanent address, ensuring that both are accurate.
7. Include the name and telephone number of an emergency contact for the patient.
8. In Section II: Determining Need for Services, list the patient's chronic medical condition(s) or ICD-10 diagnosis(es).
9. State the reason for referral to assessment and check the appropriate request type: EPD Waiver, Hospital, Reassessment, Initial assessment, Change in patient condition, or State Plan LTSS.
10. If applicable, specify the retroactive coverage request effective date for nursing facilities.
11. If you selected ‘Change in patient condition,’ describe how the patient's condition has changed since the last assessment.
12. In Section III: Physician/APRN Information, provide the ordering physician's or APRN's name, telephone number, and address.
13. Include the National Provider Identifier number and fax number for the ordering physician or APRN.
14. Finally, ensure that the ordering physician or APRN signs and dates the form, certifying that long-term care services and supports are medically necessary.
15. After completing the form, you can save changes, download, print, or share the Prescription Order Form Dc as needed.

Complete your documents online today for a smooth submission process!