FAX COVER SHEET

FOR

COPES Skilled Nursing Authorization Approval – SSPS Code 5290

ATTENTION: COPES Program Manager FAX: (360) 438-8633

TOTAL NUMBER OF PAGES: ______________

Section 1 – To Be Completed by CM/SW/RN Requesting Approval to use SSPS Code 5290

Client Name: ______________________________

(Last) (First)

Case Manager/Social Worker/CNC (Please Print):

Name: ______________________________ Office: _____________________________

(Last) (First)

Telephone: (____)______________________FAX: (____)______________________

E-Mail: _____________________________

c Provider Contracted with AAA

c Current CA and SP attached documenting special circumstances

Comments:

Section 2 – To Be Completed by COPES Program Manager or Designee

ATTENTION: _________________________________________

c APPROVED for Maximum of ___ days, effective: ______________________

c DENIED

c Further information or modification to request needed: