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COUNTY OF SANTA CARACAS SENIOR NUTRITION PROGRAMMEDICAL EXCEPTION REQUEST Proxy meals NAME OF PARTICIPANT (LAST, FIRST, MIDDLE)BENEFIT MONTH AND YEAR SNP ID CUMBERSOME SITE, ___ ___, (circle one)

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How to fill out medical exception request- proxy

01

Step 1: Obtain the necessary form for the medical exception request-proxy.

02

Step 2: Fill out the patient's personal information, including name, date of birth, and medical record number.

03

Step 3: Provide detailed information about the medical condition or treatment that requires a proxy to fill out the form.

04

Step 4: Clearly state the reason why the patient is unable to fill out the form themselves.

05

Step 5: Have the patient or their legal guardian sign and date the form, giving permission for a proxy to fill it out on their behalf.

Who needs medical exception request- proxy?

01

Individuals who are physically or mentally incapable of filling out the medical exception request form themselves.

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What is medical exception request- proxy?

A medical exception request-proxy is a formal request made by a qualified individual on behalf of a patient to request coverage for a medical service or treatment that is not typically covered under the patient's insurance plan.

Who is required to file medical exception request- proxy?

The qualified individual who is authorized to act on behalf of the patient is required to file a medical exception request-proxy.

How to fill out medical exception request- proxy?

To fill out a medical exception request-proxy, the qualified individual must provide detailed information about the patient's medical condition, the requested service or treatment, and any supporting documentation.

What is the purpose of medical exception request- proxy?

The purpose of a medical exception request-proxy is to seek coverage for a medical service or treatment that is deemed medically necessary for the patient's health and well-being, but is not typically covered under the insurance plan.

What information must be reported on medical exception request- proxy?

The medical exception request-proxy must include information such as the patient's diagnosis, the recommended treatment or service, supporting medical documentation, and a statement explaining why the requested service is necessary for the patient's health.

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