Apply online at wahealthplanfinder.org or submit a paper application (HCA 18-001P) by: Fax: 1-855-867-
4467 or Email Apple@hca.wa.gov
Updated 05/04/2023
AEM TO BE IMAGED
Fax
To: MEDS
From:
Fax: 1-866-841-2267
Hospital/Facility:
Phone: 1-800-562-3022
Phone:
Re: AEM Application
Fax:
Number of pages(including fax cover sheet):
Client Information:
Name:
Washington Healthplanfinder ID:
ACES ID:
Date(s) of Service:
Applying for Coverage:
Hospital Emergency Room
Cancer Treatment
Hospital Inpatient Treatment
Dialysis
Outpatient Surgery
Anti-rejection Medications
Documents Included (Check all that apply):
UB04
Cancer Treatment Plan/ Pathology Report
History & Physical
Dialysis Flow Charts/ Current Treatment Plan
Discharge Summary
Anti-rejection Medication Treatment Plan
Comments:
