D1323 - Authority to Install/Modify - Home/Access Modifications

Form ID
For providers
Occupational therapist (general)

This form is used in conjunction with a request for Rehabilitation Appliances Program (RAP) home/access modifications.

If you are using an Apple computer and want to fill out your form electronically, please download the form and open it with Acrobat 7 or later.

How can I access this form?
Form file format