/ Tennessee Department of Children’s Services
Health Services Authorization for Non-TennCare Eligible

TO BE COMPLETED BY DEPARTMENT OF CHILDREN’S SERVICES

DCS Region
DCS County / Child’s last Name
Child’s Social Security # / Child’s First Name / Child’s MI
TFACTS ID:
Custody Non custody / Child’s Date of Birth / Child’s Gender
M
F / Service is being provided to:
Child
Parent
Other family
Name of individual to whom service is being provided if not child
TFACTS ID / Name of Health Provider
(Hospital, Treatment Center) / Name of Individual Treating Provider:
(doctor or therapist) / Health Service description:
(doctor visit, medication, therapy, hospital)
Reason DPA is being utilized:
Not eligible for TennCare or Health insurance
Additional information:
Check all applicable
individual is undocumented
Youth Development Center
Mt.VN Vision Taft Woodland HWilder
CPS investigation
Reasonable efforts for Parent
Other
Explanation:
For Fiscal Use only
Allotment Code
Cost Center
DPA #
County Code / Request for use of DPA
Family Service Worker
Health Advocate Representative
YDC Health Administrator
Name:
EI#
Telephone #
Signature:______
Team Leader
Supervisor
Central Office Health Advocacy
Name:
EI#
Telephone #
Signature:______

TO BE COMPLETED BY HEALTH SERVICES PROVIDER (VENDOR)

Name of Health Provider (Vendor)
(Hospital, Treatment Center) / Name of Individual Treating Provider
Standard Claim forms to be received by providers include: CMS 2500, UB92, ADDA (dental), or Pharmacy standard invoice. The form must include the federal tax ID and the provider signature block certifying the treatment was provided.
Reimbursements for services is authorized through state regulation, and includes reimbursement with the Medicare fee schedule or rates otherwise set forth in the DPA.
By signature, the Vendor is agreeing to delegated purchase authority requirements, Attachment A.
Signature of Health Provider/Vendor: Tax ID: / Date:

Attach the provider Standard Claim to this Justification for Health Services/Authorization to Vendor. Providers may submit directly to DCS Health Payables in the UBS Building. Health Providers serving youth in DCS Youth Development Centers return form to the appropriate YDC.

DCS Health Payables / Mountain View YDC / Woodland Hills YDC / Wilder YDC
315 Deaderick Street / 809 Peal Lane / 3965 Stewards Lane / 134870 Hwy 59
UBS Building, 8th Floor / Dandridge, TN 37725 / Nashville, TN 37243 / Somerville, TN 38068
Nashville, TN 37243-1290

Check the “Forms” Webpage for the current version and disregard previous versions. This form may not be altered without prior approval.

Distribution: DCS Health Payables

CS-0533, Health Services Authorization for Non-TennCare EligiblesRDA 2876

Rev: 01/16 Page 1