The form names the Servicing Provider, the Beneficiary and the Prescribing Provider.
Requested Service Data: Diagnosis Code, Procedure Code, Time Required, Frequency or Units, Estimated Charges and a Description of Services, DME and Supplies.
For DME, Home Health, Private Duty Use Only: the Requesting Physician certifies a Face-to-Face encounter between the beneficiary and an allowed prescriber.
Allowed prescriber: Primary Physician, Nurse Practitioner, Certified Nurse Mid-Wife, Physician Assistant or Acute or Post-Acute Physician.
Home Health: Skilled Nurse, PT, OT, SLP, HHA or Private Duty.
| Question | Answer |
|---|---|
| Form Name | 719A |
| Form Length | 1 page |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 3 min |
| Edition | June 2018 |
| Issuing agency | Government of the District of Columbia Department of Health Care Finance |
| Matches the agency's file | Yes, checked October 7, 2026 |
| Other names | 719A, 719-A, 719 A, Form 719A, Prior Authorization Request |
| Issuing Authority | DC Department of Health Care Finance (DHCF) |
| Who Can File | Physicians and authorized prescribers |
| Form Purpose | Prior authorization for medical services and supplies |
| Official source | 719A (Rev June 2018), Government of the District of Columbia Department of Health Care Finance |
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