Washington State Health Care Authority Forms

This form is used for conducting the initial health screening of children entering foster care in Washington.

This form is used for notifying Washington HCA/Medicaid about the hospice services provided.

This prescription form is used by healthcare providers in Washington for prescribing medication to patients.

This form is used for health homes in Washington to obtain consent from adolescents for sharing their personal information.

This document is used for obtaining consent to share information about adolescents in Casas de Salud in Washington.

This form is used for requesting authorization for a hearing aid in Washington state. It is required to obtain coverage for the device.

This form is used for authorizing the release of pharmacy information in the state of Washington.

This Form is used for requesting an extension on the limitation for incontinent supplies and gloves in Washington state.

This form is used for submitting a public disclosure request in the state of Washington.

This form is used for requesting client records in the state of Washington.

This document is used for attesting to the accuracy and truthfulness of certain information in the state of Washington.

This document is a cover sheet for a Security Risk Analysis (SRA) form used in Washington. The SRA form assesses potential security risks and vulnerabilities for specific purposes.

This form is used for reviewing and coordinating patient referrals in Washington.

This form is used to request authorization for hospice services, including PPC (Palliative Performance Category), in Washington state.

This form is used for evaluating hospital beds in the state of Washington. It includes information about the bed's design, functionality, and safety features.

This form is used for requesting an injection of Infliximab medication in the state of Washington.

This form is used for requesting intravenous iron in the state of Washington.

This form is used for providing justification for the use of the Miscellaneous Enteral Nutrition Procedure Code (B9998) in Washington.

This Form is used for applying to the Kidney Disease Program (KDP) in Washington state. It is for individuals who are seeking eligibility for the program due to kidney disease.

This form is used for providing justification for using the miscellaneous parenteral supply procedure code (B9999) in the state of Washington.

This form is used for requesting low air-loss therapy systems in the state of Washington.

This form is used for requesting authorization for Lutetium Lu 177 Dotate (Lutathera) treatment in Washington.

This Form is used for Medicaid providers in Washington to disclose information about their services.

This form is used for obtaining authorization for catheters in the state of Washington by demonstrating medical necessity.

This form is used for determining the medical necessity for wheelchair purchase for clients in nursing facilities in Washington state. It helps determine if a patient requires a wheelchair and if it should be covered by insurance.

This form is used for assessing the medical necessity of a wheelchair purchase for home clients in Washington state.

This form is used for requesting Nucala (Mepolizumab Sc Injection) in Washington.

This form is used for requesting Opdivo (Nivolumab) medication in Washington.

This form is used for conducting an assessment of oral enteral nutrition by dietitians in the state of Washington. It helps gather information about a patient's nutritional needs and goals.

This form is used for requesting expedited prior authorization for thickeners for children aged 1 to 20 years old in Washington state.

This form is used for children in Washington who require expedited prior authorization for oral enteral nutrition. It is used to assist in the authorization process and documentation for this type of nutritional support.

This Form is used for patients seeking oral health services in Washington who speak Korean. It provides an attestation for the patient to verify their understanding and agreement to the services provided.

This Form is used for patients in Washington state who are participating in the Oral Health Connections program and need to provide attestation of their eligibility, in Lao language.

This form is used for Somali-speaking patients in Washington to provide an attestation regarding oral health connections.