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 1150 ADMINISTRATIVE 2017-2023

1150 ADMINISTRATIVE 2017-2023

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Waiver. The prescribing practitioner must sign and date the MA 325 form and retain the prescriber copy in his/her own files. IF YES - FACILITY NAME 12B. IF NO - CARETAKER S 13A. PRESCRIBER S NAME LICENSE NUMBER MEDICAL SPECIALTY TELEPHONE NO. Send the department s DHS copy to the appropriate address below for the type of items/service requested Early Intervention Inpatient 1150 Waiver Services PO Box 2675 Harrisburg PA 17105-2675 PO Box 8042 17105-8042 JCAHO Certified Residential Treatment...
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