Echo Home Health Attestation Form - Health Net printable pdf download

Form

ECHO Home Health Attestation

for the Provider

Beneficiary name:

Sponsor SSN:

Beneficiary date of birth:

In order to qualify for Extended Care Health Option (ECHO) Home Health Care, the patient must be homebound and have skilled needs.

TRICARE Policy Manual Chapter 9, Section 15.1 (ECHO Home Health Care (EHHC)) requires the provider attest the beneficiary is

homebound. Please complete the attestation and identify the skilled needs required. This documentation will be required every 90 days.

A. Homebound: In order for this beneficiary to be eligible for EHHC, your attestation confirming the beneficiary is homebound as

defined by 32 CFR 199.2 is required. 32 CFR 199.2 defines homebound as:

1. There exists a normal inability to leave home and, consequently, leaving home would require considerable and taxing effort.

2. Absence from the home is for the need to receive health care treatment.

3. Other absences from the home are infrequent or of relatively short duration. For example, attending a religious service, an

occasional trip to the barber, a walk around the block or a drive, only if the absences are undertaken on an infrequent basis and

are of relatively short duration.

4. The patient is under the age of 18 or receiving maternity care AND leaving the home would place the patient at medical risk.

5. Absences from the patient’s primary residence are for the purpose of attending an educational program in a public or private

school that is licensed and/or certified by a state.

B. Please identify which skilled needs are needed (please enclose supporting documentation):

Technology (check all that apply)

Interventions (check all that apply)

ventilator, continuous

tracheostomy change and care

ventilator, intermittent

trach suctioning:

q 1 hr

q 1-4 hrs

q 4 hrs or >

tracheostomy

NG/G-tube feeds:

continuous

q 2-4 hrs

q 4 hrs or >

CPAP, BiPAP

dressing changes:

q 8 hrs

> q 8 hrs

oxygen, continuous

intermittent cath:

qd/prn

q 4 hrs

q 8 hrs

q 12 hrs

oxygen, intermittent

IV/TPN:

Continuous

q 8 - 16 hrs

q 4 - 7 hrs

< 4 hrs

G-tube, continuous

special therapy/description

G-tube, continuous with reflux

QID Description: ________________________________________________________

NG-tube, continuous

TID Description: _________________________________________________________

NG-tube, bolus

BID Description: _________________________________________________________

IV therapy, continuous

QD Description: _________________________________________________________

last hospitalization: _____________

specialized monitor description (for example, I&O): ___________________________

____________________________________________________________________________

other: ___________________________

____________________________________

medication/route/frequency _______________________________________________

____________________________________________________________________________

____________________________________

___________________________________________________________________

C. Number of hours requested based on skilled needs (hours cannot be requested to cover employment, seeking employment,

deployment, or education of the primary caregiver):

_____hours per day and _____days per week

I attest this beneficiary (choose one):

is homebound

is not homebound

Date: ______/______/___________

Provider’s signature:

Provider’s printed name:

Please complete this form and fax to 1-888-299-4181

PF0414x043x0514

Echo Home Health Attestation Form - Health Net

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