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DC DHCF Prescription Order Form (ePOF) for LTCSS

The DC Department of Health Care Finance requires a Prescription Order Form (POF) before it will assess a beneficiary for long-term services and supports, or for personal care aide services for managed care enrollees. A physician or APRN orders the assessment and attests the services are medically necessary. Since January 2025 the form is completed online as the electronic POF (ePOF).

Who completes it

The person submitting the POF on the beneficiary's behalf enters patient information, the reason for referral and scheduling contacts in Sections I and II. The ordering physician or APRN completes Section III and signs, attesting they examined the patient.

Submitting and payment

How to submit it
Complete the online ePOF and click Submit, which sends it to DHCF's assessor designee; organizations with DC Care Connect access print and upload it there instead of faxing or emailing.
Who pays
Ordering providers must be enrolled with DC Medicaid; those enrolled only as ordering or referring providers receive no payment for claims they submit.

Good to know

  • The physician or APRN signature can be requested by email, which sends the clinician a signing link, or by fax for a handwritten signature that is then uploaded.
  • Once the physician or APRN has completed the form, no edits are allowed, so patient details and diagnoses should be final before it goes for signature.
  • At least one diagnosis related to the services ordered is required. Initial nursing facility entries should include a completed PASRR screen.
  • Faxed or emailed forms from DC Care Connect users are refused except for individuals new to DC Medicaid, traditional MCO or CASSIP enrollees, and hospital providers.

Get the official form

Download the current version from the source each time; forms change without notice.

DHCF Prescription Order Form (POF) for Long Term Care Services and Supports

Official page

Get the note ready with Vero

This form is completed online with District of Columbia Department of Health Care Finance (DHCF), Long Term Care Administration, so there is no PDF to fill. Vero Scribe writes the visit note it draws on, so the details are ready when you complete it.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Who can sign the DC Prescription Order Form?

Only the ordering physician or advanced practice registered nurse, who must be enrolled as a DC Medicaid provider. By signing, the clinician attests they examined the patient and that long-term care services and supports are medically necessary. DHCF offers streamlined enrollment for ordering and referring providers.

Can the DC POF still be faxed?

Organizations with access to DC Care Connect must upload the form there, and faxed or emailed POFs from them are not accepted, with three exceptions: an initial assessment for someone not known to DC Medicaid, an enrollee in a traditional MCO or CASSIP, or a hospital provider. Others can fax or email a printed ePOF.

What does the DC POF ask for?

Section I covers patient identity, Medicaid number, contact details and language needs. Section II lists chronic conditions, the reason for referral, such as an initial assessment, recertification or change in condition, and the request type. Section III holds the physician or APRN's name, address, NPI, phone, signature and date.