Washington's Health Care Authority uses the HCA 13-847 for Apple Health fee-for-service home health authorization, mainly limitation extensions for skilled nursing and therapy visits and requests for clients with AEM coverage. A clinician meets it because the plan of care, including provider orders, must be attached. HCA reviews the client-specific medical justification and why the client cannot get skilled care in the community.
The home health agency completes the form, including agency and clinical contacts, units used and requested, related diagnoses and the justification. The ordering practitioner's plan of care and orders go with it.
Download the current version from the source each time; forms change without notice.
Home Health Authorization Request
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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The plan of care, including provider orders, must be attached. When faxing, the HCA 13-835 General Information for Authorization form goes first as page one, with no separate fax coversheet, followed by the 13-847 and the plan of care.
Why home health is needed or why the request does not meet program criteria, the client-specific medical justification and services to be provided, why the client cannot access the skilled care in the community, and how long services are expected to last. It also asks for units already used for each discipline.