C727 HOME HEALTH CARE SERVICES P.O. BOX 2415 EDMONTON, AB T5J 2S5 Care Authorization FAX: 780 427-5863 1-800-661-1993 WCB Claim Number Please print clearly or type. Worker’s Surname First Name and Initial Personal Health Number Date of Birth (yyyy/mm/dd) Date of Accident (yyyy/mm/dd) Address City/Town Province Postal Code Telephone Number Telephone Number Claim Owner’s Name Provider’s Name Telephone Number Assessment Date (yyyy/mm/dd) Submission Date (yyyy/mm/dd) Description of Assessment and Treatment Plan Details from REGISTERED (RN) RN Assessment Findings (please provide full details) Attached Documents: C642 Assessment Report C728 Homemaking Plan C726 Supplies C729 Personal Care Plan RN to provide detail of hours needed and travel plan. RN Recommended Hours of Service Rationale For Level of Care Daily Weekly *Monthly Sample of how to enter *31 days x 8 hrs RN required for administration of 7 days x 8 hrs hours of service 8 hrs = 56 hrs = 248 hrs medication injections * MONTHLY is mandatory Registered Nurse (RN) Licensed Practical (LPN) Health Care Aide (HCA) No mileage paid within city limits unless previously approved by a Health Care Consultant Travel plan From To KM Total Travel Time Outside of city required (one way) Anticipated resolution of care date (yyyy/mm/dd): RN Coordinator’s Name (Print) Telephone Number Fax Number RN Coordinator’s Signature Date signed (yyyy/mm/dd) Claim Owner: The provider must receive a signed copy of the C727. Fax the signed copy to the provider and place the newly signed copy on the claim file Owner Signature for Authorization Date signed (yyyy/mm/dd)
P.O. BOX 2415 EDMONTON, AB T5J 2S5 FAX: 780 427-5863 1-800-661-1993 C727 HOME HEALTH CARE SERVICES Care Authorization Please print clearly or type. WCB Claim Number Worker’s Surname First Name and Initial Personal Health Number Date of Birth (yyyy/mm/dd) Date of Accident (yyyy/mm/dd) Address City/Town Province Postal Code Telephone Number Claim Owner’s Name Telephone Number Provider’s Name Telephone Number Assessment Date (yyyy/mm/dd) Submission Date (yyyy/mm/dd) Description of Assessment and Treatment Plan Details from REGISTERED (RN) RN Assessment Findings (please provide full details) Attached Documents: C642 Assessment Report C728 Homemaking Plan C726 Supplies C729 Personal Care Plan RN to provide detail of hours needed and travel plan. RN Recommended Hours of Service Rationale For Level of Care Daily Weekly *Monthly Sample of how to enter hours of service * MONTHLY is mandatory 8 hrs 7 days x 8 hrs = 56 hrs *31 days x 8 hrs = 248 hrs RN required for administration of medication injections Registered Nurse (RN) Licensed Practical (LPN) Health Care Aide (HCA) Travel plan No mileage paid within city limits unless previously approved by a Health Care Consultant Outside of city required (one way) From To KM Total Travel Time Anticipated resolution of care date (yyyy/mm/dd): RN Coordinator’s Name (Print) Telephone Number Fax Number RN Coordinator’s Signature Date signed (yyyy/mm/dd) Claim Owner: The provider must receive a signed copy of the C727. Fax the signed copy to the provider and place the newly signed copy on the claim file Owner Signature for Authorization Date signed (yyyy/mm/dd)