Client Name: Client EIS #: Client MaineCare #: Care Monitor: Waiver Identifier: Care Coordinator: Effective Dates of Current Care Plan: CC Email: To CC # Proposed effective dates of service Additional Notes: change/add/delete: To Reason for Request: Date Resource Coordinator Rec’d Document: Add the following services/items: Type of Service Units Per Provider Name and Service Location Auth ID Delete the following services/items: Type of Service Units Per Provider Name and Service Location Auth ID
Client Name: Client EIS #: Client MaineCare #: Waiver Identifier: Care Monitor: Care Coordinator: CC Email: CC # Effective Dates of Current Care Plan: To Proposed effective dates of service change/add/delete: To Reason for Request: Date Resource Coordinator Rec’d Document: Additional Notes: Add the following services/items: Type of Service Units Per Provider Name and Service Location Auth ID Delete the following services/items: Type of Service Units Per Provider Name and Service Location Auth ID
Section%2020%20Authorization%20Request%20Form%2010.18.2017%201.docx