Form MA325 "1150 Administrative Waiver Request Form" - Pennsylvania

What Is Form MA325?

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

Form Details:

  • Released on February 1, 2015;
  • The latest edition provided by the Pennsylvania 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 printable version of Form MA325 by clicking the link below or browse more documents and templates provided by the Pennsylvania Department of Human Services.

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Download Form MA325 "1150 Administrative Waiver Request Form" - Pennsylvania

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1150 ADMINISTRATIVE
WAIVER REQUEST FORM
MA 325
TO BE USED FOR INPATIENT HOSPITAL SERVICES, JCAHO--CERTIFIED MENTAL HEALTH
RESIDENTIAL TREATMENT FACILITY CARE, LONG TERM CARE, AND EARLY INTERVENTION ONLY.
The 1150 Administrative Waiver Request (MA 325 form) must be completed
by the prescribing physician when requesting an 1150 waiver.
Instructions for the proper completion of the form are found on the inside of
this cover sheet.
(a) Read the instructions before attempting to complete the MA 325 waiver
request from.
(b) Improper completion of the request form may result in a processing
delay and/or rejection.
(c) Incomplete or illegible forms will be returned unprocessed.
MA 325 2/15
1150 ADMINISTRATIVE
WAIVER REQUEST FORM
MA 325
TO BE USED FOR INPATIENT HOSPITAL SERVICES, JCAHO--CERTIFIED MENTAL HEALTH
RESIDENTIAL TREATMENT FACILITY CARE, LONG TERM CARE, AND EARLY INTERVENTION ONLY.
The 1150 Administrative Waiver Request (MA 325 form) must be completed
by the prescribing physician when requesting an 1150 waiver.
Instructions for the proper completion of the form are found on the inside of
this cover sheet.
(a) Read the instructions before attempting to complete the MA 325 waiver
request from.
(b) Improper completion of the request form may result in a processing
delay and/or rejection.
(c) Incomplete or illegible forms will be returned unprocessed.
MA 325 2/15
INSTRUCTIONS FOR THE MA 325
1150 WAIVER REQUEST FORM
PRESCRIBING PRACTITIONER
The form may be used for requesting one or two items or services. Use additional forms when requesting more than
two items or services; in such cases, the forms must be sent to Headquarters simultaneously.
1.
When requesting a single item/service the prescribing practitioner must complete box 8A entering a name or
basic description of the item/service requested and box 8B entering the number of units of the item/service
requested for a specific time period. Example: 6 cases per month, must be entered in box B along with the
number of months the item/service will be needed,
If the prescribing practitioner is also the provider, boxes C and D must be completed.
If the prescribing practitioner is not the provider, the name of the provider must be entered in box C. Also
enter the provider’s M.A.I.D. number, and phone number.
Enter the provider’s address in D. Enter the usual fee, if known, in box E
2.
When requesting two item/services, box 9A must be completed as described in 1, above.
3.
The prescriber must enter identifying information in boxes 10, 11, 12, 12A, 12B, 13A, 13B, 14, and 15.
4.
The prescriber must enter primary diagnosis in box 14 with its corresponding ICD Code. If the recipient has
a secondary condition or disorder, the prescriber must enter appropriate information in box 15.
5.
The medical documentation should include a full description of the recipient’s impairments, copies of lab
reports, and diagnostic studies, medical history, current hospital discharge summaries, or any additional
significant reports or documentation to support the 1150 Waiver Request.
6.
The prescribing practitioner must sign and date the MA 325 form and retain the prescriber copy in his/her
own files. Send the department’s (DHS) copy to the appropriate address below for the type of items/service
requested:
JCAHO
Early Intervention
Inpatient
Certified Residential Treatment
Long Term Care
1150 Waiver Services
1150 Waiver Services
1150 Waiver Services
DHS/OMHSAS
PO Box 8042
PO Box 8025
PO Box 2675
Division of Clinical Review & Consultation
Harrisburg, PA
Harrisburg, PA
Harrisburg, PA
RTF Section
17105-8042
17105-8025
17105-2675
PO Box 2675
Harrisburg, PA
17105-2675
INCOMPLETE OR ILLEGIBLE MA 325 forms will be returned to the prescriber, unprocessed.
DEPARTMENT OF HUMAN SERVICES
The Headquarters staff reserves the right to contact other providers and to negotiate fees for items/services requested in boxes 8A and 9A.
Headquarters staff will determine if the Exception Request meets the criteria for approval.
Notice of the Department’s decision will be sent to:
a.
the prescribing practitioner
b.
the recipient
c.
the Provider(s) concerned
MA 325 2/15
CONTROL NUMBER
1150
ADMINISTRATIVE WAIVER REQUEST FORM
1.
2. RECIPIENT NAME:
LAST
FIRST
3. RECIPIENT NUMBER
4. RES. CODE 5. SOCIAL SECURITY NUMBER
6. DATE OF BIRTH
-
-
7. ADDRESS
ZIP CODE
8A. ITEM/SERVICE REQUESTED
M.A.I.D. NUMBER
9A. ITEM/SERVICE REQUESTED
M.A.I.D. NUMBER
8B. QUANTITY
NUMBER OF MONTHS
9B. QUANTITY
NUMBER OF MONTHS
8C. PROVIDER NAME:
9C. PROVIDER NAME:
8D. ADDRESS
9D. ADDRESS
TELEPHONE NUMBER
TELEPHONE NUMBER
8E. REQUESTED FEE
PER MONTH
TOTAL
9E. REQUESTED FEE
PER MONTH
TOTAL
$
$
$
$
$
$
8F. INDICATE HOW LONG THE ITEM/SERVICE IS REQUIRED
9F. INDICATE HOW LONG THE ITEM/SERVICE IS REQUIRED
£
£
£
£
£
£
1 - 3 MONTHS
4 - 6 MONTHS
EXTENDED PERIOD
1 - 3 MONTHS
4 - 6 MONTHS
EXTENDED PERIOD
8G. INDICATE DATE ITEM/SERVICE IS TO BEGIN
9G. INDICATE DATE ITEM/SERVICE IS TO BEGIN
10.
£
£
YES
NO - IS REQUEST BEING MADE AS A RESULT OF EPSDT SCREEN? (IF YES, INDICATE DATE OF SCREEN)
DATE
11.
£
£
YES
NO - IS THERE A SCHOOL MEDICAL REFERRAL FORM, PA 295, ON FILE?
12.
£
£
YES
NO - IS RECIPIENT IN HEALTH CARE FACILITY (IF YES INDICATE NAME OF FACILITY BELOW - IF NO IDENTIFY CARETAKER(S))?
12A. IF YES - FACILITY NAME
12B. IF NO - CARETAKER(S)
13A. PRESCRIBER’S NAME
LICENSE NUMBER
M.A.I.D. NUMBER
MEDICAL SPECIALTY
13B. PRESCRIBER’S ADDRESS
TELEPHONE NO.
14. PRIMARY DIAGNOSIS
ICD DIAGNOSIS CODE
15. SECONDARY DIAGNOSIS
ICD DIAGNOSIS CODE
16. ALL OF THE FOLLOWING INFORMATION FROM THE PRESCRIBING PHYSICIAN IS ESSENTIAL IN ORDER TO ESTABLISH THE MEDICAL NECESSITY FOR THE REQUESTED
ITEM/SERVICE. THE INFORMATION SUBMITTED SHOULD BE SPECIFIC TO THE REQUESTED ITEM/SERVICE.
16A. SUBMIT MEDICAL HISTORY OR COPY OF DISCHARGE SUMMARY
16B. SUBMIT COPIES OF ANY SIGNIFICANT DIAGNOSTIC STUDIES PERFORMED
PRESCRIBER’S SIGNATURE
DATE
DHS COPY
MA 325 2/15
CONTROL NUMBER
1150
ADMINISTRATIVE WAIVER REQUEST FORM
1.
2. RECIPIENT NAME:
LAST
FIRST
3. RECIPIENT NUMBER
4. RES. CODE 5. SOCIAL SECURITY NUMBER
6. DATE OF BIRTH
-
-
7. ADDRESS
ZIP CODE
8A. ITEM/SERVICE REQUESTED
M.A.I.D. NUMBER
9A. ITEM/SERVICE REQUESTED
M.A.I.D. NUMBER
8B. QUANTITY
NUMBER OF MONTHS
9B. QUANTITY
NUMBER OF MONTHS
8C. PROVIDER NAME:
9C. PROVIDER NAME:
8D. ADDRESS
9D. ADDRESS
TELEPHONE NUMBER
TELEPHONE NUMBER
8E. REQUESTED FEE
PER MONTH
TOTAL
9E. REQUESTED FEE
PER MONTH
TOTAL
$
$
$
$
$
$
8F. INDICATE HOW LONG THE ITEM/SERVICE IS REQUIRED
9F. INDICATE HOW LONG THE ITEM/SERVICE IS REQUIRED
£
£
£
£
£
£
1 - 3 MONTHS
4 - 6 MONTHS
EXTENDED PERIOD
1 - 3 MONTHS
4 - 6 MONTHS
EXTENDED PERIOD
8G. INDICATE DATE ITEM/SERVICE IS TO BEGIN
9G. INDICATE DATE ITEM/SERVICE IS TO BEGIN
10.
£
£
YES
NO - IS REQUEST BEING MADE AS A RESULT OF EPSDT SCREEN? (IF YES, INDICATE DATE OF SCREEN)
DATE
11.
£
£
YES
NO - IS THERE A SCHOOL MEDICAL REFERRAL FORM, PA 295, ON FILE?
12.
£
£
YES
NO - IS RECIPIENT IN HEALTH CARE FACILITY (IF YES INDICATE NAME OF FACILITY BELOW - IF NO IDENTIFY CARETAKER(S))?
12A. IF YES - FACILITY NAME
12B. IF NO - CARETAKER(S)
13A. PRESCRIBER’S NAME
LICENSE NUMBER
M.A.I.D. NUMBER
MEDICAL SPECIALTY
13B. PRESCRIBER’S ADDRESS
TELEPHONE NO.
14. PRIMARY DIAGNOSIS
ICD DIAGNOSIS CODE
15. SECONDARY DIAGNOSIS
ICD DIAGNOSIS CODE
16. ALL OF THE FOLLOWING INFORMATION FROM THE PRESCRIBING PHYSICIAN IS ESSENTIAL IN ORDER TO ESTABLISH THE MEDICAL NECESSITY FOR THE REQUESTED
ITEM/SERVICE. THE INFORMATION SUBMITTED SHOULD BE SPECIFIC TO THE REQUESTED ITEM/SERVICE.
16A. SUBMIT MEDICAL HISTORY OR COPY OF DISCHARGE SUMMARY
16B. SUBMIT COPIES OF ANY SIGNIFICANT DIAGNOSTIC STUDIES PERFORMED
PRESCRIBER’S SIGNATURE
DATE
PRESCRIBER COPY
MA 325 2/15
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