Form SFN606 "Medicaid out of State Services Certification" - North Dakota

What Is Form SFN606?

This is a legal form that was released by the North Dakota Department of Human Services - a government authority operating within North Dakota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2012;
  • The latest edition provided by the North Dakota Department of Human 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 fillable version of Form SFN606 by clicking the link below or browse more documents and templates provided by the North Dakota Department of Human Services.

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Download Form SFN606 "Medicaid out of State Services Certification" - North Dakota

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MEDICAID OUT OF STATE SERVICES CERTIFICATION
Clear Fields
NORTH DAKOTA DEPARTMENT OF HUMAN SERVICES
MEDICAL SERVICES DIVISION
SFN 606 (2-2012)
ONLY TO BE COMPLETED WHEN THE 'UNAVAILABLE' EXCEPTION IS REQUESTED
Name of Child
Medicaid ID Number
In accordance with Medical Services Division Out-of-State - Unavailable Services Policy and through my care of the above-
named child, I have determined that necessary services (described on the corresponding Request for Prior Authorization for
Out-of-State Services (SFN 769)-required) are unavailable for this child for the following reasons (select one or more):
To ensure continuity of care, and if the in-state referring provider has determined that the follow up should be provided at
the facility that performed the surgery or services; a follow up to a previously approved and performed out-of-state
surgery or specialty service.
Comments (Required)
A set of related inter-dependent services for diagnosis and treatment are needed and the entire set of services is not
available in-state.
Comments (Required)
After the in-state referring provider consults with the in-state specialist, it is determined that the wait time for in-state
speciality services is expected to negatively impact the diagnosis or treatment.
Comments (Required)
Only one in-state specialist is available to provide the service; however, adverse previous client or referring provider
experience with the specialist substantiates the need to seek services out-of-state.
Required - Attach a written complaint/report which is prepared by the referring provider or the family.
I acknowledge that the services requested will be reviewed by the Department of Human Services for medical necessity. I also
acknowledge that the Department will conduct post audits and that my certification is subject to this review.
Signature-Provider Requesting Out-of-State Services
Date
Signature-Pediatric Practice Director or Medical Director
Date
MEDICAID OUT OF STATE SERVICES CERTIFICATION
Clear Fields
NORTH DAKOTA DEPARTMENT OF HUMAN SERVICES
MEDICAL SERVICES DIVISION
SFN 606 (2-2012)
ONLY TO BE COMPLETED WHEN THE 'UNAVAILABLE' EXCEPTION IS REQUESTED
Name of Child
Medicaid ID Number
In accordance with Medical Services Division Out-of-State - Unavailable Services Policy and through my care of the above-
named child, I have determined that necessary services (described on the corresponding Request for Prior Authorization for
Out-of-State Services (SFN 769)-required) are unavailable for this child for the following reasons (select one or more):
To ensure continuity of care, and if the in-state referring provider has determined that the follow up should be provided at
the facility that performed the surgery or services; a follow up to a previously approved and performed out-of-state
surgery or specialty service.
Comments (Required)
A set of related inter-dependent services for diagnosis and treatment are needed and the entire set of services is not
available in-state.
Comments (Required)
After the in-state referring provider consults with the in-state specialist, it is determined that the wait time for in-state
speciality services is expected to negatively impact the diagnosis or treatment.
Comments (Required)
Only one in-state specialist is available to provide the service; however, adverse previous client or referring provider
experience with the specialist substantiates the need to seek services out-of-state.
Required - Attach a written complaint/report which is prepared by the referring provider or the family.
I acknowledge that the services requested will be reviewed by the Department of Human Services for medical necessity. I also
acknowledge that the Department will conduct post audits and that my certification is subject to this review.
Signature-Provider Requesting Out-of-State Services
Date
Signature-Pediatric Practice Director or Medical Director
Date