Administrative Waiver Request Form

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Administrative Waiver Request Form Printable pdf

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1150 ADMINISTRATIVE

WAIVER REQUEST FORM

MA 325

TO BE USED FOR INPATIENT HOSPITAL SERVICES, JCAHO--CERTIFIED MENTAL HEALTH

RESIDENTIAL TREATMENT FACILITY CARE, LONG TERM CARE, AND EARLY INTERVENTION ONLY.

The 1150 Administrative Waiver Request (MA 325 form) must be completed

by the prescribing physician when requesting an 1150 waiver.

Instructions for the proper completion of the form are found on the inside of

this cover sheet.

(a) Read the instructions before attempting to complete the MA 325 waiver

request from.

(b) Improper completion of the request form may result in a processing

delay and/or rejection.

(c) Incomplete or illegible forms will be returned unprocessed.

MA 325 2/15

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