WA HCA 13-967 2018-2025 free printable template
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Chronic Opioid Attestation
Please fax responses to: 18666681214
Form 13835A must be submitted as a cover sheet
For more information go to: https://www.hca.wa.gov/billersproviders/programsandservices/opioids
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How to fill out WA HCA 13-967
How to fill out WA HCA 13-967
01
Obtain the WA HCA 13-967 form from the appropriate state website or office.
02
Read the instructions carefully to understand the requirements.
03
Fill out the personal information section, including your name, address, and contact details.
04
Provide details about your insurance coverage, including policy numbers.
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Indicate your reason for completing the form and any necessary supporting information.
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Review the form for accuracy and completeness.
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Signature: Sign and date the form in the designated areas.
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Submit the form as instructed, either by mail or electronically as specified.
Who needs WA HCA 13-967?
01
Individuals seeking assistance from Washington Health Care Authority programs.
02
Those who need to report changes in their health care coverage or eligibility.
03
Applicants for Medicaid or other health-related assistance in Washington State.
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What is WA HCA 13-967?
WA HCA 13-967 is a form used in Washington State for reporting certain health care information to the Health Care Authority.
Who is required to file WA HCA 13-967?
Entities that provide health care services in Washington and are subject to health care reporting requirements are required to file WA HCA 13-967.
How to fill out WA HCA 13-967?
To fill out WA HCA 13-967, follow the instructions provided on the form, ensuring all required information is accurately completed and all sections are addressed.
What is the purpose of WA HCA 13-967?
The purpose of WA HCA 13-967 is to collect and standardize health care data, which aids in health policy development, research, and analysis within Washington State.
What information must be reported on WA HCA 13-967?
The information that must be reported on WA HCA 13-967 includes details about services provided, patient demographics, and financial data related to health care services.
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