PDF
Word
Form PA-109 Prior Authorization Form - Incontinence Supply Hope Waiver - South Dakota
What Is Form PA-109?
This is a legal form that was released by the South Dakota Department of Social Services - a government authority operating within South Dakota. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is Form PA-109?A: Form PA-109 is a Prior Authorization Form.
Q: What is the purpose of Form PA-109?A: The purpose of Form PA-109 is to request prior authorization for incontinence supplies under the Incontinence Supply Hope Waiver in South Dakota.
Q: What is the Incontinence Supply Hope Waiver?A: The Incontinence Supply Hope Waiver is a program in South Dakota that provides coverage for incontinence supplies for eligible individuals.
Q: Who can use Form PA-109?A: Individuals in South Dakota who are eligible for the Incontinence Supply Hope Waiver can use Form PA-109.
Q: What information is required on Form PA-109?A: Form PA-109 requires information such as the individual's personal details, medical diagnosis, healthcare provider information, and details of the requested incontinence supplies.
Form Details:
- Released on March 1, 2021;
- The latest edition provided by the South Dakota Department of Social 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 PA-109 by clicking the link below or browse more documents and templates provided by the South Dakota Department of Social Services.
Download Form PA-109 Prior Authorization Form - Incontinence Supply Hope Waiver - South Dakota
1
2
