Form Hca 13 870 PDF Details

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.

QuestionAnswer
Form NameForm Hca 13 870
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names13_870 informationsharingconsent

Form Preview Example

Limitation Extension Request

Incontinent Supplies and Gloves

Attention: DME Program Manager

Durable Medical Equipment (DME) Program Management Unit

PO Box 45535 Olympia, WA 98504-5535

Fax:1-866-668-1214

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 13-794).

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 non-family caregivers? Yes

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 state-funded living

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 13-870 (11/13)