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IDAHO DEPARTMENT OF CORRECTION <br />Medical Request for Payment Authorization <br />Appendix A Page 1 of 2 <br />401.06.03.087 v 2.1 <br />(Appendix last updated: 9/26/08) <br />The purpose of the Medical Request for Payment Authorization form is to streamline the authorization/billing/payment <br />process and hopefully reduce the number of requests that have to be returned for clarification. <br />Please fill out as many of the sections on the form as possible. Failure to do so may result in your request being <br />returned to you to provide the missing information, which will delay authorization. Most of the form is self-explanatory. <br />Please note that “Inmate IDOC number” and “Responsible Licensed Medical Provider” are required fields. IDOC <br />Health Services staff will provide the Inmate IDOC number upon the initial request, but ask that you also make note of <br />the number so that you can use it for future medical requests. <br />Type of Service Requested: If you are only requesting medication authorization, please only check the “Medication <br />Request” box. If you have already requested a medical/dental/mental health visit and it has been authorized and you <br />only require medications, you do not need to check the “visit” box again. Checking only one (1) box will help IDOC <br />Health Services staff determine what is actually being requested, which will help them reduce the number of <br />payments being denied due to the lack of clarity or lack of information. However, you may request more than one (1) <br />service on the same form. <br />Details of Current Illness/Injury: Please briefly state the reason for the service being requested. If you are only <br />requesting medications, skip this section. <br />Treatment Plan: List treatment recommendation (e.g., needs glasses, medical visit, x-ray, etc.). If you are only <br />requesting medications, skip this section. <br />List Medications Requested: If you are only requesting medications you will need to complete this section of the <br />form. IDOC Health Services staff are now requiring more information when you are requesting medications. You will <br />only need to request authorization for a medication one (1) time (provided the offender is still housed in the county jail <br />and has not left and come back). However, there will be exceptions — for example, antibiotics will not have an <br />unlimited authorization. <br />Note: Prompt, accurate documentation of the form enables the IDOC Health Services staff to efficiently process all <br />bills submitted by the county and in turn ensure prompt payment. When submitting bills, please specify whether <br />the county or the vendor is to receive payment. <br /> <br />IDOC Health Services Staff Contact Information <br />Phone: (208) 658-2128 Fax: (208) 327-7007 <br />Technical Records Specialist II <br />Vicky Brady <br />Phone: 208-658-2128 <br />E-mail: vbrady@idoc.idaho.gov <br />Fax: 208-327-7007 <br /> <br />If you have any billing questions or concerns, please contact Vicky. <br /> <br />Health Authority (Health Services Director) <br />Rona Siegert, RN <br />Phone: 208-658-2047 <br />E-mail: rsiegert@idoc.idaho.gov <br />Fax: 208-327-7007 <br /> <br />Registered Nurse (Virtual Prisons Program) <br />Zarah Martin, RN <br />Phone: 208-672-3434 <br />E-mail: zmartin@idoc.idaho.gov <br />Fax: 208-327-7007 <br /> <br />If you have any medical/dental questions or concerns, please contact Rona or Zarah. <br /> <br />Mailing Address: <br />Idaho Department of Correction <br />Attn: Health Services <br />1299 N. Orchard, Suite 110 <br />Boise, Idaho 83706