CAP/C Service Authorizations &

Deviation Forms

Valid Service Authorization

A valid Service Authorization (SA) must have the following:

1. Recipient name and medical identification number (MID)2. Start and end dates3. Hours authorized per week4. Billing code signifying level of care required5. Name of the case manager and agency6. Name of the provider7. Case manager's signature

The following slides contain examples of actual

Service Authorizations & Deviation Forms.

Name of Provider Name of Case

Manager and Agency

Recipient Name and MID

Billing Code

Case Manager Signature

Hours Authorized Per Week

Start and End Dates

Service Authorization – Nurse, Aide, or Attendance Care

Name of Provider

Name of Case Manager and Agency

Recipient Name and MID

Billing Code

Case Manager Signature

Start and End Dates

Service Authorization – page 1 of 2

Recipient Name and MID

Billing Code

Case Manager Signature

Hours Authorized Per Week

Service Authorization – page 2 of 2

Recipient Name

Hours Authorized Per Week and Billing Codes

Case Manager Signature

Service Authorization – page 1 of 2

Patient MID

Start and End Dates

Name of Provider

Name of Case Manager and Agency

Please note that additional information has been provided, including the total number of respite hours and the start and end dates for respite hours.

Hours Authorized

Case Manager Signature

Service Authorization – page 2 of 2

Start and End Dates

Name of Provider

Name of Case Manager and Agency

Billing Code

Deviation FormA valid deviation form must have the following:

1. An actual missed date of service or the range of dates for the week of service

2. It must also include a specific number of missed service hours.

3. Why service was missed4. Who assumed care for child

Deviation Form

Missed Date of Service Missed Service Hours

Why service was missed.

Please include the name of the person who assumed care for the child. For example, “mother cared for child during vacation”.