DHCF PRESCRIPTION ORDER FORM (POF)

 

This form must be uploaded to DC Care Connect or forwarded to the DHCF assessment vendor. Items indicated with a * are required. The electronic prescription order form (ePOF) instruction page can be accessed at https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/publication/attachments/Prescription%20Order%20Form%20Instructions.pdf

 

 

SECTION l: PATIENT INFORMATION

 

 
 
 
 
 
mm/dd/yyyy
 
Phone
 
Phone
 
 
 
 
 
Phone
 
 
 
 
 
 

 

SECTION ll. DETERMINING NEED FOR SERVICES

 

 
 
 
 
 
 
 
 
 

Submitting individual

 
 
Phone
 
 
 
 
 

 

SECTION Ill: PHYSICIAN/APRN INFORMATION

 

 
 
Phone
 
 
 
 
Drop your files here
 

For individuals who wish to be enrolled in Medicaid-certified nursing facility, please send this form along with a completed Pre-Admission Screening Resident Review (PASRR) to the DHCF assessment vendor.