Instructions: Computer-assigned when authorization is entered.

Instructions: Enter the appropriate person number from Section F for child authorized for services.

Instructions: SN = SSI/Disabled Children’s Program

NOTE: This block must be entered when adding a new authorization.

Instructions: Enter one of the following codes.

• 1 = Open.
• 6 = Closed.
• R = Renew Request (Diapers/Formula).

Instructions: Enter the code from the list below to show type of purchase request. A code is needed for each item authorized.

• C = Child Care for developmentally disabled.
• D = Diapers.
• E = Equipment, supplies, developmental aides, or educational materials.
• F = Formula.
• P = Professional services.
• Skating lessons, swimming lessons, medical services not covered by Title XIX.

Instructions: Computer-entered when vendor is on DHS vendor file. If number is not on file, enter vendor name.

Instructions: Computer-entered when vendor is on DHS vendor file. If vendor not on file, enter address. Use second line, Vendor address 2, if needed.

Instructions: Computer-entered when vendor on DHS vendor file. If vendor not on file, enter city.

Instructions: Computer-entered when vendor on DHS vendor file. If vendor not on file, enter 2 digit state code.

Instructions: Computer-entered when vendor on file. If vendor not on file, enter 5 digit zip code.

Instructions: Enter phone number, including area code.

Instructions: Enter the FEI/SSN number of vendor as shown on DHS vendor file. If this vendor is not on file, enter FEI/SSN without a prefix. Vendor number is not required on requests for diapers or formula. County entries will be ignored on these type requests

Instructions: Computer enters begin date for diaper and formula requests. If the authorization date processed is day 01 through 15, the begin date will be next month. If the process date is after the 15th, the beginning date will be the following month.

Instructions: Computer enters the expiration date for diaper and formula requests. The expiration date will be 6 months from the date in Block K45, Begin/Change Date.

Instructions: Enter the quantity of each item being authorized. If request is for diapers, enter number needed per day. If request is for formula, enter number of cans to be used daily.

NOTE: AFS HRMS will convert D and F to monthly total.

Instructions: Pre-entered by computer for each line item when authorization request is for equipment or professional services.

Instructions: Entered by AFS, Health Related and Medical Services, for diaper and/or formula requests.

Instructions: Enter type of unit requested from list of codes below. If unit is unknown, leave blank.

• BX = Box
• CS = Case
• EA = Each
• PR = Pair

Instructions: State Office use only. Entered by AFS Health Related and Medical Services Unit for each item authorized by county. This code is used only for equipment or professional services.

Instructions: Enter the catalog code of item authorized. This is used for equipment authorizations requests only. Leave blank if request is used for diapers, formula, or professional services.

Instructions: Enter a concise description of the item or service being authorized. If request is for diapers, enter size. If request is for formula, enter the brand of formula in this field.

Instructions: Enter the estimated unit cost of item of service authorized. Enter amount using dollars and cents. Leave blank if request is for diapers or formula.

Instructions: Computer enters the total cost of each item/service authorized using entries made in the quantity, unit, and unit cost fields.

Instructions: State Office use. Entered by AFS Health Related and Medical Services Unit using one of the following codes:

• A = Approved and ADM-92 sent.
• B = Approved, but no ADM-92 required – diapers / formula.
• M = Approved, but moved to new authorization.
• N = Not approved.
• P = Pending further information from county/vendor.
• Q = Pending further information from county/vendor and moved to another authorization.
• R = Pending further information from county. Need pictures and product specifications.
• S = State Office Use – requires separate ADM-2.

Instructions: Enter date (month, day, year) when item received by local office. This will document payment of vendor invoice.

Instructions: State Office use. Entered AFS Health Related and Medical Services to generate claim.

Instructions: Computer-entered for approved requests.

Instructions: Purchase authorization number assigned and entered by AFS, Health Related and Medical Services Unit.