Revision of Home and Community Services intake and referral form

Washington State Health Care Authority sent this bulletin at 12/20/2023 08:00 AM PST

December 20, 2023

Revision of Home and Community Services intake and referral form (DSHS 10-570)

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

What do I use the form for?

The intake and referral form (DSHS 10-570) 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.

What's new, changed, or clarified?

The Home and Community Services intake and referral form's section "Applicant Information" was revised to add the following question:

"Is Applicant receiving hospice services at home?"

Can I still use an older version?

No. Begin using the revised form as of the date of this bulletin.

Where can I find the form?

On the DSHS website:

Home and Community Services intake and referral form (DSHS 10-570)

Contact

Contact Dru Aubert with any questions.

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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Nondiscrimination

The Washington State Health Care Authority (HCA) complies with all applicable federal and Washington state civil rights laws and is committed to providing equal access to our services. Visit HCA’s website to view complete nondiscrimination statements.