Nurse Delegation: Request For Additional Units printable pdf download

Nurse Delegation: Request For Additional Units

AGING AND LONG-TERM SUPPORT ADMINISTRATION

Nurse Delegation: Request For Additional Units

To be completed by Delegating Nurse

1. RND NAME

2. RND TELEPHONE NUMBER

3. RND E-MAIL ADDRESS

4. CLIENT NAME

5. CASE MANAGER NAME

6. CASE MANAGER TELEPHONE NUMBER

7. CASE MANAGER E-MAIL

8. I will need

more units in addition to the 36 units already authorized for the month of

This will allow me to bill for a total of

units for the month.

9. Reason Additional Units Needed:

A. For insulin, complete the section below. (No additional narrative required)

Initial visit

Units:

New caregiver(s)

Units:

Supervisory visit

Units:

Total number Caregivers delegated insulin:

B. Other than insulin please list reasons units needed:

11. DATE REQUESTED

12. REQUESTING ND SIGNATURE

13. UNITS APPROVED

14. ND PROGRAM MANAGER SIGNATURE

15. DATE APPROVED

E-mail this form to Doris Barret

barreda@dshs.wa.gov

TO SUBMIT:

Fax – 360-438-8633 Telephone – 360-725-2553

NURSE DELEGATION: REQUEST FOR ADDITIONAL UNITS

DSHS 13-893 (REV. 02/2015)

Nurse Delegation: Request For Additional Units