Request For Medical Authorization - State Of Hawaii Acs Department Of Human Services
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1STATE OF HAWAII
ACS
Department of Human Services
P.O. BOX 2561
Med-QUEST Division
Honolulu, Hawaii 96804-2561
Page number _______ of _______
ACS USE ONLY
N
Urgent Request
Extension Request
ew Request
PA No.:
REQUEST FOR MEDICAL AUTHORIZATION
Check only ONE – Different Types of Services Must Be Requested on Separate 1144 Forms.
O
BH – Psych. Testing/ & Detox
GT – Transportation
LT – Long Term Care
S- Out of State Services
DE
– Dental
HE- Home Health
MD- Professional Services
RE – Rehabilitation Services
DM – Appl./DME/ Supplies
OP – Outpatient Facility
LN – Sign Language Interpretation
SR – Hospice
*** This Form should NOT be used for: Incontinence Supplies, EPSDT Medically Fragile Services and Drugs. ***
NOTE: INCOMPLETE FORM WILL DELAY THE AUTHORIZATION PROCESS. Approval of this request is not an authorization for payment or an approval of
charges. Payment by the Medicaid Program is contingent on the patient being eligible and the provider of service being certified by Medicaid. The provider of service must
verify patient eligibility at the time the service is rendered. Authorization expires 60 days from date of approval unless otherwise noted by the consultant.
PLEASE PRINT INFORMATION CLEARLY
Medicaid Identification Number:
Patient Name (Last, First, M.I.):
Gender
Date of Birth
[ ] M
[ ] F
_____ / _____ / _____
Medicare Coverage? [ ] Yes
[ ] No
Currently at: [ ] Home [ ] SNF/ICF/ICF-MR Facility [ ] Other: ___________________________
Patient Mailing Address (St., Apt. No., City, Zip Code)
name
Is Patient receiving Medicare Home
Health Benefits? [ ] Yes
[ ] No
Supplier Section
Physician Section
(Circle Rent or Repair)
Purchase
Rent/
Period Requested
Service Description
Procedure Code
QTY
Price
Repair
From
To
1
mm/dd/yyyy mm/dd/yyyy
2
mm/dd/yyyy mm/dd/yyyy
3
mm/dd/yyyy mm/dd/yyyy
4
mm/dd/yyyy mm/dd/yyyy
5
Physician Section
Physician/ Supplier Comments
Diagnosis(es):
Justification:
If applicable: Serial No.:
Attachment: [ ] Yes
[ ] No
MSRP Attached:
[ ] Yes
[ ] No
I certify that the items and quantities above are prescribed by the physician indicated below and will be provided by the supplier.
mm/dd/yyyy
Physician/Provider Signature:
Date:
Print Physician/ Provider Name:
Provider Number:
Print Contact Name:
Fax Number:
Telephone Number:
(if different from Physician)
I certify that the items and quantities above are prescribed by the physician indicated above and will be provided by the supplier.
Supplier Signature:
Date:
Print Supplier/ Company Name:
Supplier Number:
Print Contact Name:
Telephone Number:
Fax Number:
To be completed by Medicaid (A= Approved
P= Pended
D= Denied
R= Revoked)
Code
Auth.
Approved Period
Modifier(s)
QTY
Consultant Comments:
Line
Code
From
To
1
2
3
4
5
Medicaid Form 1144 (Revised 09/03)
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