Get Wa Dshs 13-628 2010-2025

The WA DSHS 13-628 form, also known as the Involuntary Treatment Act Patient Claim Information form, is essential for providing demographic information required for eligibility determinations under the Involuntary Treatment Act. This guide will walk you through the process of completing the form online in a clear and supportive manner.

Follow the steps to fill out the WA DSHS 13-628 online easily.

1. Press the ‘Get Form’ button to obtain the WA DSHS 13-628 form and open it in the provided online editor.
2. Begin by entering the client’s last name, first name, and middle initial in the designated fields. This information is crucial for identification.
3. If available, input the Provider One Client ID; otherwise, leave this field blank.
4. Provide the client’s address at the time of hospitalization, ensuring accuracy for eligibility processing.
5. Indicate if the client is homeless or transient by checking the corresponding box or boxes, if applicable.
6. Enter the Washington county of residence listed on the client’s medical card or the county where the client resided prior to hospitalization.
7. If known, fill in the RSN (Regional Support Network) responsible for the client’s services.
8. Input the client’s date of birth in the specified format.
9. Select the client’s gender from the options provided.
10. Provide the client’s Social Security Number for processing.
11. Detail the name of the Evaluation and Treatment (E&T) facility where involuntary services were provided.
12. Record the date of detention when a designated mental health professional signed the initial detention or revocation petition.
13. Specify the date when the individual was discharged from the Evaluation and Treatment facility.
14. Fill in the name of the ITA provider signing this form.
15. Indicate the title of the person who is providing their signature.
16. Enter the telephone number of the ITA provider submitting this form.
17. Obtain the signature of the ITA provider to complete the form, confirming all the information is accurate.
18. Finally, save your changes, and you may choose to download, print, or share the completed form as needed.

Complete your WA DSHS 13-628 online today for a streamlined submission process.