WA HCA Form 13-952 2014-2025 free printable template
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Retroactive Health Care Coverage Request form MAGI Medicaid Uses this form only if the applicant has completed an application for health care coverage. Primary Applicant / Head of Household Information
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How to fill out retroactive health care coverage
How to fill out WA HCA Form 13-952
01
Download the WA HCA Form 13-952 from the official website.
02
Read the instructions carefully before starting to fill out the form.
03
Provide your personal information in the designated sections, including your name, address, and phone number.
04
Fill in the information regarding your health care provider and the services needed.
05
Specify the purpose of the authorization in the appropriate field.
06
Sign and date the form at the bottom to acknowledge your consent.
07
Review the completed form for any errors or missing information before submission.
08
Submit the form as instructed, either online or by mail, based on your preference.
Who needs WA HCA Form 13-952?
01
Individuals who are applying for health care coverage under Washington State's Health Care Authority.
02
Those who need to authorize the release of their medical information.
03
Patients seeking to appoint a representative for assistance with health care decisions.
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What is WA HCA Form 13-952?
WA HCA Form 13-952 is a form used in Washington State for reporting healthcare-related information to the Health Care Authority.
Who is required to file WA HCA Form 13-952?
Healthcare providers and organizations that are involved in delivering services and receiving reimbursement from the Washington Health Care Authority are required to file WA HCA Form 13-952.
How to fill out WA HCA Form 13-952?
To fill out WA HCA Form 13-952, individuals must provide accurate data regarding patient care, services rendered, and billing information, adhering to the guidelines specified by the Health Care Authority.
What is the purpose of WA HCA Form 13-952?
The purpose of WA HCA Form 13-952 is to collect standardized data for evaluating healthcare services, ensuring compliance, and facilitating proper reimbursement from the Health Care Authority.
What information must be reported on WA HCA Form 13-952?
The information that must be reported on WA HCA Form 13-952 includes patient demographics, service codes, billing amounts, and details of the services provided.
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