Fillable Home Health Care & Hospice Authorization Request Form printable pdf download

Home Health Care & Hospice Authorization Request Form

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OT, PT, AND SPEECH THERAPY MAY BE REQUESTED

ON THE SAME PRIOR AUTHORIZATION FORM.

PLEASE USE A SEPARATE FORM

FOR SKILLED NURSING.

Home Health Care & Hospice Authorization Request Form

Fax: 313-745-0399

Medical Management Phone: 877-501-0958

Date of Request:

_____________

Member’s Name: ________________________________________________

DOB: ________________

DMC Care ID#: ______________________________

Other Insurance: _____________________________________

Member’s Diagnosis: _____________________________________ ICD-10 Codes: ____________________________

Ordering Physician: ____________________________________ Specialty: ___________________________________

Provider/Facility Name: ________________________________________________________________________________

Contact Person: _______________________________

Phone#: _________________ Fax#: ___________________

Provider Tax ID #: ________________________________

NPI #: _______________________________

*MUST INCLUDE CURRENT CLINICAL & COPY OF CPC FORM

HOME CARE SERVICES

HCPCS CODE

NUMBER OF

LENGTH OF

DATES OF SERVICE

VISITS

SERVICE

(Including Evaluation)

HOSPICE SERVICES

HCPCS CODE

NUMBER OF

LENGTH OF

DATES OF SERVICE

VISITS

SERVICE

MEDICAL MANAGEMENT USE ONLY:

Denied

Approved:

Authorization#: ___________________

Staff Initials: _____________________

Date: ________________

PROVIDER MUST NOTIFY MEMBER: CO- PAYS & DEDUCTIBLES WILL APPLY FOR THIS SERVICE

NOT G

. P

UTHORIZATION

OES

UARANTEE

AYMENT

EPENDENT ON

LIGIBILITY ON

ATE OF

ERVICE

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information. If you are not the intended recipient(s), you are hereby notified that any dissemination, unauthorized review, use, disclosure or distribution of this

communication and any materials contained in any attachments is prohibited. If you receive this message in error, or are not the intended recipient(s), please immediately

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DMC Care 2016

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