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Incomplete, Illegible or Inaccurate Forms Will Be Returned to Sender

Incomplete, Illegible or Inaccurate Forms Will Be Returned to Sender

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Completed by a UCare Delegated Care Coordinator. NEW OR CURRENT EW DATE SPAN TO SERVICES/PROCEDURES/ ITEMS REQUESTED ELDERLY WAIVER SERVICES Denial Termination Reduction Reason Code DTR Comments e.g. inpatient admission/out of country date/services reduced via CL Tool select Service Description Service Description select an option Frequency e.g. hrs per week/daily/monthly Rate Per Unit if negotiated Provider Name Provider UCare ID/NPI Provider Phone Fax U7829 Page 1 of 2. Please complete the...
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