Washington Apple Health uses this one-page request when a client needs more incontinence supplies or gloves than the program's quantity limits allow. The clinician documents the diagnoses, daily frequency of use, recent changes, medications, any bowel or bladder program, and for gloves the number of non-family caregivers. It is sent with the HCA prescription form 13-794 to the Medical Equipment Unit.
The vendor or clinician fills in the contact and client details in Section 1; the clinician answers Section 2, and the physician or other prescribing provider signs.
Download the current version from the source each time; forms change without notice.
Incontinent Supplies Limitation Extension Request
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The form states that all supplies are authorized for one year and that new documentation must be submitted yearly. If the client still needs more than the standard limits after that year, a fresh request with current documentation is needed to continue the higher quantities.
For incontinent supplies: the diagnoses requiring more supplies, daily frequency of use, whether frequency changed and why, medications affecting the amount needed, whether a bowel or bladder program was tried and its outcome, and the type of incontinence. Glove requests ask similar questions plus caregiver and residence details.