All provider notice: 2020 update of DSHS social service Intake and Referral form (HCA message on behalf of DSHS)

Washington State Health Care Authority sent this bulletin at 06/03/2020 04:00 PM PDT

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The Health Care Authority (HCA) is sending this message on behalf of the Department of Social and Health Services (DSHS).

Intake and referral form (DSHS 10-570) updated in 2020

Home and Community Services is updating its statewide Intake and Referral form (DSHS 10-570).

What do I use the form for?

The Intake and Referral form is used to communicate to social services intake that an individual is requesting a functional assessment for long-term services and supports (LTSS).

The form is for statewide use and includes instructions for where to send the completed form.

Can I still use an older version?

No. The updated form replaces all previous versions of the form currently in use around the state. The revised form is effective June 3, 2020.

Does this replace the Nursing Facility Notice of Action form (DSHS 15-031)?

No, it does not. The Nursing Facility Notice of Action form (DSHS 15-031) is used to report changes to the financial worker on all active and pending Classic Medicaid recipients.

The latest version of DSHS 15-031 includes instructions on the type of Medicaid case and if the notice of action is needed.

Where can I find these forms?

On the DSHS website:

Home and Community Services Intake and Referral form (DSHS 10-570)
Nursing Facility Notice of Action form (DSHS 15-031)

About the Health Care Authority (HCA)

The Washington State Health Care Authority (HCA) is committed to whole-person care, integrating physical health and behavioral health services for better results and healthier residents.

HCA purchases health care for more than 2.5 million Washington residents through Apple Health (Medicaid), the Public Employees Benefits Board (PEBB) Program, the School Employees Benefits Board (SEBB) Program, and the COFA Islander Health Care Program. As the largest health care purchaser in the state, we lead the effort to transform health care, helping ensure Washington residents have access to better health and better care at a lower cost.

Please do not reply directly to this message. For more information, visit the HCA website, where you'll also find contact information.

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