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Effective Date: 



Updated: 4/2003


To obtain a statement from the client's medical provider that certain items were medically necessary.


When to Prepare

The worker prepares Form H1263 when a client submits as an incurred medical expense a bill for routine dental services, prosthetic devices, walking aids, or special shoes/support devices for feet.

Number of Copies

The worker completes an original and one copy.


After the client or personal representative signs the Authorization to Release Information, the worker sends the original to the medical provider, enclosing a postage-paid envelope. The worker files the copy in the case record. After the original is returned to the department, the worker files the original in the case record and destroys the copy.

Form Retention

Keep the original copy according to the retention requirements of the case record.

Detailed Instructions

Inside Address — Type name and address of client's attending physician.

Date — Self-explanatory

Eligibility Specialist — Enter the eligibility specialist's signature.

Office Address and Telephone No. — Self-explanatory.

Name of Patient — Self-explanatory.

Client No. — Self-explanatory.

List Medically Necessary Items — Enter the type of device for which medical necessity must be documented.

Signature — Obtain the signature of the client or personal representative.

Date — Enter the date the form is signed.

This authorization expires on — An expiration date or an expiration event that relates to the individual.

Authority of Personal Representative — Describe why the representative has the authority to represent the client. Refer to the Medicaid Eligibility Handbook for defintions.

Signatures of Witnesses — The signatures of two witnesses are entered, if required.