Health and recovery services administration (hrsa) prescription form - hca wa 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name and date of birth in Section I. Ensure accuracy as this information is crucial for identification.
3. Next, provide the diagnosis and specify the length of need. Indicate if rental is applicable by selecting either 'Less than 6 months' or 'Greater than 6 months', and fill in the number of months if necessary.
4. In Section II, list the items required along with their quantities. Specify the frequency of use for each supply to ensure proper understanding of needs.
5. Proceed to Section III where you will enter the physician’s printed name, address, telephone number, fax number, city, state, zip code, and NPI number.
6. Finally, the physician must sign and date the form. Remember that signatures and date stamps are not accepted; a handwritten signature is required.

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