Dshs 13 720 2026

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The document outlines the authorization process for prescribing SUBOXONE® through the Health Care Authority (HCA) for patients enrolled in state-certified chemical dependency treatment. It details the necessary sections to be completed by the treatment agency, patient, physician, and pharmacy, along with instructions for submitting the form for prior authorization. The document emphasizes patient confidentiality and the conditions under which HCA will reimburse for SUBOXONE®, including a limit of six months of continuous use.

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Click ‘Get Form’ to open the dshs 13 720 in the editor.
Begin with Section 1, where you will enter the name of the DBHR certified chemical dependency treatment agency and its agency number. This information can be found in the Directory of Certified Chemical Dependency Services in Washington State.
Move to Section 2, the Patient Section. Fill in the patient’s name, birthdate, and Medicaid ProviderOne number. Ensure that the patient signs the authorization for disclosure of confidential information.
In Section 3, provide details about the physician including their name, telephone number, address, and SUBOXONE DEA ID number. The physician must sign and date this section.
Finally, complete Section 4 by entering the pharmacy's name, NPI number, contact details, and address. Once completed, send the form via fax to DBHR for prior authorization.

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How do I submit documents to DSHS Washington state?

Look for a second email with subject line: [SECURE] Email Documents to MyDocs@DSHS.WA.GOV Then follow the steps in that message to attach and send your documents. In the future, you can respond to this email to send documents electronically, so you may want to store it in your email inbox.

What is the income limit for DSHS in Washington state?

Basic Food Eligibility and Benefits Household SizeMonthly Gross Income 3 $4,442 4 $5,358 5 $6,275 6 $7,1927 more rows

Does DSHS verify income?

DHS outsources this function to a third-party vendor with specific expertise in EV. The data DHSs Employment Verification vendor relies on to verify past or current employment and income details comes from NFCs Payroll/Personnel System (PPS).

How do they verify your income?

Supporting Documents Paystubs. W2s or other wage statements. IRS Form 1099s. Tax filings. Bank statements demonstrating regular income. Attestation from a current or former employer.

How do I prove income in Washington state?

Some example documents that prove income include: Payroll statements for the last 60 days. The first 2 pages your most recent tax return. Self-employment Profit and Loss document for the past 3 months.

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