Get And Sign STATE OF HAWAII Department Of Human Services Med QUEST Division ACS P Med quest 2007-2021 Form

Program is contingent on the patient being eligible and the provider of service being certified by Medicaid. The provider of service must verify patient eligibility at the time the service is rendered. Authorization expires 60 days from date of approval unless otherwise noted by the consultant. No. City Zip Code name Is Patient receiving Medicare Home Health Benefits Yes Gender M F Supplier Section Physician Section Service Description Circle Rent or Repair Procedure Code QTY Purchase Price...