Form SFN769 Request for Service Authorization for Out-of-State Services - North Dakota

Form SFN769 Request for Service Authorization for Out-of-State Services - North Dakota

What Is Form SFN769?

This is a legal form that was released by the North Dakota Department of Health and Human Services - a government authority operating within North Dakota. As of today, no separate filing guidelines for the form are provided by the issuing department.

FAQ

Q: What is Form SFN769?
A: Form SFN769 is a request forservice authorization for out-of-state services in North Dakota.

Q: Who needs to fill out Form SFN769?
A: Healthcare providers in North Dakota who need authorization for out-of-state services.

Q: What information is required on Form SFN769?
A: Form SFN769 requires information about the healthcare provider, the patient, the requested services, and the reason for the out-of-state treatment.

Q: How long does it take to get approval for out-of-state services?
A: The approval process can vary, but it typically takes several weeks to receive a decision.

Q: What if my request for out-of-state services is denied?
A: If your request is denied, you have the right to appeal the decision.

Q: Can I submit Form SFN769 electronically?
A: Yes, the North Dakota Department of Human Services allows electronic submission of Form SFN769.

Q: Are there any fees associated with Form SFN769?
A: There are no fees for submitting Form SFN769.

Q: Who can I contact for more information about Form SFN769?
A: You can contact the North Dakota Department of Human Services for more information about Form SFN769.

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Form Details:

  • Released on August 1, 2014;
  • The latest edition provided by the North Dakota Department of Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form SFN769 by clicking the link below or browse more documents and templates provided by the North Dakota Department of Health and Human Services.

Download Form SFN769 Request for Service Authorization for Out-of-State Services - North Dakota

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