Get Wa Hca 13-879 2017-2026

Filling out the WA HCA 13-879 form correctly is essential for clients seeking to pay for healthcare services not covered by the Health Care Authority. This guide provides clear and detailed instructions to support you through the online completion process.

Follow the steps to successfully complete the WA HCA 13-879 form online.

1. Click the ‘Get Form’ button to access the WA HCA 13-879 form and open it in the editor.
2. Begin by entering the client’s printed name and their ID number in the designated fields, ensuring accuracy for proper identification.
3. Fill in the provider’s printed name alongside the provider number to establish the agreement between client and provider.
4. Indicate the specific service(s) or item(s) to be provided and the anticipated date of service in the appropriate section to clarify what is being billed.
5. Enter the relevant CPT/CDT/HCPCS billing code for each service in the designated field to ensure correct billing.
6. Complete the amount to be paid by the client for the services rendered, clearly indicating the total expected payment.
7. Choose the applicable reason for billing the client by checking the relevant boxes in the provided list, ensuring all circumstances are covered.
8. Fill out the dates of any Exception to Rule (ETR) requests or prior authorization (PA) actions taken regarding the service, attaching any necessary notices.
9. Make sure both the client and provider sign and date the form. If an interpreter was involved, be sure to include their printed name, signature, and date as well.
10. Finally, review all sections for completeness and accuracy before saving your changes, and proceed to download, print, or share the completed form as necessary.

Complete your WA HCA 13-879 form online today to ensure timely healthcare service payments.