Dshs Forms Dda Request For Additional Units Nurse Delegation (Nd)
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DEVELOPMENTAL DISABILITITIES ADMINISTRATION (DDA)
DDA Request for Additional Units
Nurse Delegation (ND)
1. REGISTERED NURSE DELEGATE’S (RND) NAME
2. CLIENT’S NAME
RND E-MAIL ADDRESS
RND TELEPHONE NUMBER (INCLUDE AREA CODE)
3. Fax completed form to DDA Nurse Delegation (ND) Coordinators (check where faxing):
Region 1 Spokane ........ Wilma Brown ............ (509) 3292940, fax (509) 568-3037,
brownWH@dshs.wa.gov
Region 1 Kennewick ..... Gail Blegen-Frost ..... (509) 374-2124, fax (509) 734-7103,
blegegd@dshs.wa.gov
Region 2 South ............. Kathleen Wood ........ (206) 568-5783, fax (206) 720-3334
woodkm@dshs.wa.gov
Region 2 North .............. Meg Hindman .......... (360) 714-5005, fax (360) 714-5001,
HindmMM@dshs.wa.gov
Region 3........................ Denise Pech ............ (253) 404-5540, fax (253)597-4368,
pechDL@dshs.wa.gov
Aging and Long-Term Support Administration (ALTSA) ND Program Manager is available for consultation.
4. I will need
more units in addition to the 100 units already authorized for the month of
. This will allow me
to bill for a total of
units for this month.
5. Reason additional units needed (check all appropriate boxes below):
A. For insulin, complete the section below (no additional narrative required).
Initial visit;
units needed.
Supervisory visit;
units needed.
New support providers / caregivers;
units needed.
Total number of support providers delegated insulin:
B. Other than insulin, please list reason(s) units needed:
ADDITIONAL COMMENTS
6. RND’S SIGNATURE
DATE
7. Unit(s) authorized:
Yes
No
DDA ND COORDINATOR’S SIGNATURE
DATE
8. ND PROGRAM MANAGER’S SIGNATURE
DATE
DDA ND Coordinators must send outcome to Teresa Martin Teresa.martin@dshs.wa.gov, DDA Program Manager and
Doris Barret RN barreda@dshs.wa.gov, ALTSA ND Program Manager.
DDA REQUEST FOR ADDITIONAL UNITS NURSE DELEGATION
DSHS 13-903 (REV. 04/2016)
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