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For State use only.APPROVED273 AT State: By: Dates of Service: REQUEST FOR SERVICE AUTHORIZATION06/2018EPSDT: SA #: FOR SERVICES NOT ADDRESSED ON OTHER FORMS (FeeforService (FFS) Program Only Not
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For services not addressed refers to the specific services or issues that were not included or covered in a particular document or agreement.
The individual or entity responsible for the services not addressed is required to file a separate document or agreement to address those services.
To fill out for services not addressed, one must clearly outline the services or issues that were not covered and propose a plan to address them separately.
The purpose of for services not addressed is to ensure that all services and issues are fully addressed and accounted for in a document or agreement, leaving no room for ambiguity or misunderstandings.
The document or agreement for services not addressed must include a detailed explanation of the omitted services or issues, as well as a proposed plan for addressing them.
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