Form Dhcs 9053 - Request For Enteral Nutrition Product(S)
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1State of California—Health and Human Services Agency
Department of Health Care Services
Genetically Handicapped Persons Program
REQUEST FOR ENTERAL NUTRITION PRODUCT(S)
GENETICALLY HANDICAPPED PERSONS PROGRAM
TELEPHONE: 1-800-639-0597
FAX NUMBER: 916-327-1112
Instructions: Initial and subsequent requests for nutrition products require completion of this form. The
following documents (dated within six months of the request date) must accompany this form:
o Special Care Center (SCC) Physician prescription or signature on the bottom of this form
o Current height and weight including Body Mass Index
o SCC Registered Dietitian (RD) assessment/plan (recommended calories and/ or
treatment plan)
o SCC medical reports
o Lab results (serum phe, plasma amino acids, etc. as indicated for the management
of medical condition)
Note: Authorizations for nutrition products will be limited to 6 MONTHS
Patient name:
GHPP number (if known):
(Resident of a licensed care facility or long term care facility?)
Yes
No
DOB:
Age:
Client’s Special Care Center :
________
Client’s SCC Physician:
_______
Pharmacy vendor name:
Telephone #:
Address:
Fax #:
Nutrition product(s) requested:
NUTRITION PRODUCT NAME
NDC CODE
AMOUNT PER
AMOUNT PER
DAY
MONTH
This is a:
Replacement Formula
Elemental Formula
Calorie Dense Product
Nutrition Additive
□
□
Route of delivery:
Enteral (bolus / continuous)
Oral
For calorie dense products only, (check applicable boxes):
Severe oral motor impairment and/or risk of aspiration or weight/length or height is at or below the
th
5
percentile
th
Growth velocity is falling or at or below the 10
percentile
th
Unable to maintain weight/length or height above the 5
percentile
(If there is a signed prescription, fax it with this completed form. The information below can be left blank.)
Physician name (print):
License #:
Signature:
Date:
Telephone #:
Fax #:
THIS FORM SHOULD NOT BE USED FOR MEDICAL FOODS
DHCS 9053 (8/07)
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