Form 719A at a glance
What it is: The 719A Prior Authorization Request is a form of the Government of the District of Columbia Department of Health Care Finance Fee-For-Service Medicaid Program.
Who signs: The Requesting Provider enters the DATE, signs and enters a Title.
The blank Form 719A: print it and complete it by hand
How to fill out Form 719A, box by box
Provider, Patient and Other Health Insurance Coverage
Enter the Provider Name, Provider Number and NPI for the Servicing Provider and for the Prescribing Provider, and the Beneficiary Name for the Patient.
Write the Address, City, State, Zip and Telephone Number for the Patient, the Prescribing Provider and the Servicing Provider, and the DCID Number, DOB and SEX of the Patient.
Enter any Other Health Insurance Coverage.
Beneficiary Location and Requested Service
Under Requested Service, mark Surgery, DME, Medical, Pharmacy, Dental, Eyewear, Hospice or Other. Under Beneficiary Location, mark Home, ICF/MR, Nursing Home, Hospital or Office.
For Home Health, mark Skilled Nurse, PT, OT, SLP, HHA or Private Duty. Write the Discharge Date.
Requested Service Data, Description and Justification
Under Requested Service Data, enter the Diagnosis Code, Procedure Code, Time Required, Frequency or Units and Estimated Charges.
Enter the Description of Services, DME and Supplies.
Enter the Justification.
For Dental Use only
For Dental Use only: denote the teeth already missing by "X", to be extracted by "?", x-rays taken by "V".
For DME, Home Health, Private Duty Use Only
The Requesting Physician Certification is for DME, Home Health, Private Duty Use Only. The requesting physician certifies that a Face-to-Face encounter, related to the primary reason the beneficiary requires Home Health or DME services, occurred on a date entered on the form between the beneficiary and the allowed prescriber, marked as Primary Physician, Nurse Practitioner, Certified Nurse Mid-Wife, Physician Assistant or Acute or Post-Acute Physician. Write the Name of allowed prescriber, Title and Date.
Under Durable Medical Equipment Face to Face Regulations, mark the box that applies. Mark Any HCPCS code for these types of DME: Transcutaneous Electrical Nerve Stimulation (TENS) unit, Rollabout Chair, Traction-cervical, Oxygen and Respiratory equipment, or Hospital beds and accessories. Mark Any item of DME that appears on the DMEPOS Fee Schedule with a price ceiling at or greater than $1,000 (checked November 12, 2026). Mark Any other item of DME that CMS adds to the list of Specified Covered Items.
Signature of the Requesting Provider
The Signature of the Requesting Provider certifies that the services requested are medically indicated and necessary for the health of this patient and that the information is true, accurate, and complete.
Sources
[1] Form 719A (June 2018), Prior Authorization Request, Government of the District of Columbia Department of Health Care Finance (the Official source link on this page).