Prescription Order Form for Long Term Care Services
This Prescription Order Form is essential for authorizing Medicaid-funded long term care services and supports. It is required by the District of Columbia's Department of Health Care Finance (DHCF). Ensure all sections are completed before submission to facilitate timely processing.
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How do I fill this out?
Filling out this Prescription Order Form is straightforward. Start by collecting all necessary patient and provider information. Ensure all required fields marked with asterisks are completed accurately.
How to fill out the Prescription Order Form for Long Term Care Services?
1
Gather necessary patient information, including Medicaid number and personal details.
2
Complete the provider's information section including the provider's name and contact details.
3
Detail the patient's medical conditions and the reason for referral.
4
Ensure the ordering physician's signature is included.
5
Submit the completed form to Liberty Healthcare Corporation via fax.
Who needs the Prescription Order Form for Long Term Care Services?
1
Healthcare providers who need to refer a patient for long-term care services.
2
Patients seeking Medicaid-funded long-term care support.
3
Social workers coordinating patient care services.
4
Family members assisting in health care decisions.
5
Medicaid administrators for processing service requests.
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What are the instructions for submitting this form?
To submit the Prescription Order Form, fax it to Liberty Healthcare Corporation at 202-698-2075. Ensure that all information is completed accurately before submission to avoid delays. For inquiries, contacting the provider directly is advised for clarification on the submission process.
What are the important dates for this form in 2024 and 2025?
There are no specific important dates listed for this form in 2024 and 2025. It is essential to check for any updates or changes in regulations from the Department of Health Care Finance.
What is the purpose of this form?
The Prescription Order Form is designed to authorize Medicaid-funded long term care services and supports for eligible patients. It outlines necessary patient information and provider details required for Medicaid processing. Completing this form accurately ensures that patients receive timely and appropriate care.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Medicaid Number: An identifier for the patient’s Medicaid eligibility.
- 2. Patient Name: Full name of the patient.
- 3. Date of Birth: The patient's date of birth in MM/DD/YYYY format.
- 4. Telephone Number: Primary contact number of the patient.
- 5. Provider Name: Name of the healthcare provider making the referral.
- 6. Reason for referral: The medical necessity for long term care.
What happens if I fail to submit this form?
Failure to submit this form can result in delays in obtaining necessary long-term care services. Patients may not receive timely treatment or support, impacting their overall health. It is crucial to ensure that all information is correctly filled out and submitted.
- Delayed Access to Care: Without this form, patients may face delays in starting essential services.
- Ineligibility for Services: Incomplete submissions may lead to denial of necessary Medicaid services.
- Administrative Confusion: Missing or incorrect information can cause administrative delays for providers.
How do I know when to use this form?
- 1. Initiating Long-Term Care: Used to start the referral process for long-term care services.
- 2. Assessment Requests: Required for requesting assessments from appropriate healthcare services.
- 3. Maintaining Medicaid Compliance: Ensures that patients meet the requirements for receiving Medicaid services.
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What information do I need to fill out the form?
You'll need patient identification details, provider information, and reasons for referral.
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Where do I send the completed form?
You need to fax the completed form to Liberty Healthcare Corporation.
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