New Referral Form
Bucks / Philadelphia Counties
Participant
First Name
Last Name
Recipient ID#
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Supports Coordinator
First Name
Last Name
SC Email
example@example.com
Surrogate Name
First Name
Last Name
Surrogate Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Surrogate Email
example@example.com
Support Service Worker Name
First Name
Last Name
Support Service Worker Number
Please enter a valid phone number.
Format: (000) 000-0000.
Support Service Worker Email
example@example.com
Waiver Type
Service (check if authorized)
Rows
Modifier
Start Date of Authorization
End Date of Authorization
Units Authorized
Frequency of Service (Per week or month)
Companion Service (W1726)
With Benefits
Without Benefits (U4)
In-Home & Comm. Supports. Lev. 3 (W7060)
With Benefits
Without Benefits (U4)
In-Home & Comm. Supports. Lev. 3, Enh. (W7061)
With Benefits
Without Benefits (U4)
Friend
Unlic. 15 min Respite. Lev. 3, 1:1 In-Home (W9862)
With Benefits
Without Benefits (U4)
Unlic. Respite Lev. 3, 1:1 In-Home
(W9798)
With Benefits
Without Benefits (U4)
Transportation-Mile (W7271)
With Benefits
Without Benefits (U4)
Other:
With Benefits
Without Benefits (U4)
Other:
With Benefits
Without Benefits (U4)
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CHANGE/TERMINATION OF SERVICE AUTHORIZATION
Change in Service Authorization
Termination of Services
Participant Name
First Name
Last Name
Recipient ID #
Effective Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
If Change in funding source, specify NEW source here:
Base
P/FDS
Consolidated
Old Procedure Code
Old Units/Dates
New Procedure Code
New Units/Dates
Submit
Should be Empty: