CAP/C Service Authorizations & Deviation Forms

Valid Service Authorization A valid Service Authorization (SA) must have the following: 1.Recipient name and medical identification number (MID) 2.Start and end dates 3.Hours authorized per week 4.Billing code signifying level of care required 5.Name of the case manager and agency 6.Name of the provider 7.Case manager's signature

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

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

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

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

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

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

Deviation Form A valid deviation form must have the following: 1.An actual missed date of service or the range of dates for the week of service 2.It must also include a specific number of missed service hours. 3.Why service was missed 4.Who assumed care for child

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.