Form HCA 13 870 is an annual report that health care organizations must file with the California Department of Public Health. The report provides information on the operations and financial performance of the organization, and it is a valuable tool for assessing the health care industry in California. The deadline for submitting Form HCA 13 870 is May 1 each year, and organizations that fail to submit the report may face penalties.
Question | Answer |
---|---|
Form Name | Form Hca 13 870 |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | 13_870 informationsharingconsent |
Limitation Extension Request
Incontinent Supplies and Gloves
Attention: DME Program Manager
Durable Medical Equipment (DME) Program Management Unit
PO Box 45535 Olympia, WA
This is confidential information intended only for the person to whom it is faxed. In addition to this form, you must send a completed HCA Rx form (HCA
To be completed by vendor or clinician
CONTACT NAME
PROVIDER NAME
PHONE NUMBER
FAX NUMBER
PROVIDER NPI NUMBER
CLINICAL CONTACT
PHONE NUMBER
FAX NUMBER
CLIENT ID
CLIENT’S NAME
To be completed by clinician
FOR INCONTINENT SUPPLIES
1.What is the medical diagnoses(s) requiring additional incontinent supplies?
2.What is the frequency of use of incontinent supplies per day?
3. Has the frequency changed recently?
Yes
No If yes, why?
4.What type of medications does the client currently use that may affect the amount of incontinent products required per month?
5.Has a bowel/bladder program been tried?
6.If yes, what was the outcome?
7.Is client dual incontinent? Yes No
FOR GLOVES
Yes
No
1.What is the medical diagnoses(s) requiring additional gloves?
2.What is the frequency of use of gloves per day?
3.Has the frequency changed recently? If yes, why?
4.Does the client have multiple
If yes, how many? |
|
How many hours per day? |
No
5.Where does the client reside?
Private home |
Adult family home or boarding home (e.g. ALF) |
FOR SIZING THAT DOES NOT FIT INTO THE ALLOWABLES
Other
1. Waist measurement_______________________ Hip Measurement__________________________________
Please note: All supplies are authorized for 1 year. New documentation must be submitted yearly.
PHYSICIAN (OR PRESCRIBING PROVIDER) SIGNATURE |
DATE |
|
|
HCA