General Information For Authorization Page 7

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Instructions to fill out the General Information for Authorization form, HCA 13-835
FIELD
NAME
ACTION
ALL FIELDS MUST BE TYPED.
29
Place of Service
52
Psychiatric Facility-Partial Hospitalization
53
Community Mental Health Center
55
Residential Substance Abuse Treatment Facility
56
Psychiatric Residential Treatment Center
57
Non-residential Substance Abuse Treatment Facility
60
Mass Immunization Center
61
Comprehensive Inpatient Rehabilitation Facility
62
Comprehensive Outpatient Rehabilitation Facility
65
End-Stage Renal Disease Treatment Facility
71
Public Health Clinic
72
Rural Health Clinic
81
Independent Laboratory
99
Other Place of Service
30
Comments
Enter any
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information
you deem
necessary.
HCA 13-835 (11/16)

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