CAP/C Service Authorizations & Deviation Forms

1. CAP/C Service Authorizations & Deviation Forms

2. A valid Service Authorization (SA) must have the following: • Recipient name and medical identification number (MID) • Start and end dates • Hours authorized per week • Billing code signifying level of care required • Name of the case manager and agency • Name of the provider • Case manager's signature Valid Service Authorization

3. The following slides contain examples of actual Service Authorizations & Deviation Forms.

4. Service Authorization – Nurse, Aide, or Attendance Care Name of Provider Name of Case Manager and Agency Recipient Name and MID Billing Code Hours Authorized Per Week Start and End Dates Case Manager Signature

5. Service Authorization – page 1 of 2 Name of Case Manager and Agency Name of Provider Recipient Name and MID Start and End Dates Billing Code Case Manager Signature

6. Service Authorization – page 2 of 2 Recipient Name and MID Billing Code Hours Authorized Per Week Case Manager Signature

7. Service Authorization – page 1 of 2 Name of Provider Name of Case Manager and Agency Recipient Name Hours Authorized Per Week and Billing Codes Patient MID Start and End Dates Please note that additional information has been provided, including the total number of respite hours and the start and end dates for respite hours. Case Manager Signature

8. Service Authorization – page 2 of 2 Name of Provider Name of Case Manager and Agency Start and End Dates Billing Code Hours Authorized Case Manager Signature

9. A valid deviation form must have the following: • An actual missed date of service or the range of dates for the week of service • It must also include a specific number of missed service hours. • Why service was missed • Who assumed care for child Deviation Form

10. Deviation Form Missed Date of Service Missed Service Hours Why service was missed. Please include the name of the person who assumed care for the child. For example, “mother cared for child during vacation”.