Missouri Confirmation of Verbal Service Authorization for Healthy Children and Youth (Form MO 580-29

The mobile form includes fields to document items such as provider information, participant, services, terms and conditions and statement of understanding. Once the mobile app is filled out a secure PDF is generated. The PDF is easy to share, and a copy is stored in your account for your records. You can also use our App Builder to personalize and customize this mobile form. A Missouri Special Health Care Needs Service Coordinator can use the app to verbally approve services. Services are to be delivered as authorized. Orders for discipline, amount, and frequency on the applicable form(s) as required in the MO HealthNet Provider Manual must match this authorization. This is not an official prior authorization. The plan of care, physician orders, and prior authorization form must be submitted to special health care needs within 90 days for services to be approved for payment. SHCN will complete the Prior Authorization form for PDN Services.