DSHS Form 13-903 "Dda Request for Additional Units Nurse Delegation" - Washington

What Is DSHS Form 13-903?

This is a legal form that was released by the Washington State Department of Social and Health Services - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2019;
  • The latest edition provided by the Washington State Department of Social and Health Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DSHS Form 13-903 by clicking the link below or browse more documents and templates provided by the Washington State Department of Social and Health Services.

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Download DSHS Form 13-903 "Dda Request for Additional Units Nurse Delegation" - Washington

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DEVELOPMENTAL DISABILITITIES ADMINISTRATION (DDA)
DDA Request for Additional Units
Nurse Delegation (ND)
1. RND NAME
2. RND TELEPHONE NUMBER
3. RND E-MAIL ADDRESS
4. CLIENT’S NAME
5. CLIENT’S DATE OF BIRTH
6. CASE MANAGER’S NAME
7. CASE MANAGER’S TELEPHONE NUMBER
8. CASE MANAGER’S E-MAIL
9. DDA NURSE DELEGATOR COORDINATOR’S NAME
10. COORDINATOR’S TELEPHONE NUMBER
11. COORDINATOR’S E-MAIL
12. I will need
more units in addition to the 100 units already authorized for the month of
. This will allow
me to bill for a total of
units for the month of
.
13. Reason additional units needed (check all appropriate boxes below):
A.
For insulin, complete the section below (no additional narrative required).
Initial visit;
units needed.
Supervisory visit;
units needed.
New support providers / caregivers;
units needed.
Total number of caregivers delegated insulin:
B.
Other than insulin, please list reason(s) units needed:
14. DATE REQUESTED
15. REQUESTING ND SIGNATURE
16. UNITS APPROVED
17. ND / NURSE SERVICE PROGRAM MANAGER SIGNATURE
18. DATE APPROVED
Scan and email additional unit request form:
Doris Barret
Nursing Service Unit Manager
Barreda@dshs.wa.gov
DDA REQUEST FOR ADDITIONAL UNITS NURSE DELEGATION
DSHS 13-903 (REV. 07/2019)
DEVELOPMENTAL DISABILITITIES ADMINISTRATION (DDA)
DDA Request for Additional Units
Nurse Delegation (ND)
1. RND NAME
2. RND TELEPHONE NUMBER
3. RND E-MAIL ADDRESS
4. CLIENT’S NAME
5. CLIENT’S DATE OF BIRTH
6. CASE MANAGER’S NAME
7. CASE MANAGER’S TELEPHONE NUMBER
8. CASE MANAGER’S E-MAIL
9. DDA NURSE DELEGATOR COORDINATOR’S NAME
10. COORDINATOR’S TELEPHONE NUMBER
11. COORDINATOR’S E-MAIL
12. I will need
more units in addition to the 100 units already authorized for the month of
. This will allow
me to bill for a total of
units for the month of
.
13. Reason additional units needed (check all appropriate boxes below):
A.
For insulin, complete the section below (no additional narrative required).
Initial visit;
units needed.
Supervisory visit;
units needed.
New support providers / caregivers;
units needed.
Total number of caregivers delegated insulin:
B.
Other than insulin, please list reason(s) units needed:
14. DATE REQUESTED
15. REQUESTING ND SIGNATURE
16. UNITS APPROVED
17. ND / NURSE SERVICE PROGRAM MANAGER SIGNATURE
18. DATE APPROVED
Scan and email additional unit request form:
Doris Barret
Nursing Service Unit Manager
Barreda@dshs.wa.gov
DDA REQUEST FOR ADDITIONAL UNITS NURSE DELEGATION
DSHS 13-903 (REV. 07/2019)