Home Health Care Preauthorization Request Form

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Home Health Care PREAUTHORIZATION REQUEST FORM  
FAX COMPLETED FORM WITH SUPPORTING MEDICAL DOCUMENTATION TO: (410) 779‐9336 
SECTION
1
MEMBER
INFORMATION
 
 
 
 
 
First Name 
Last Name 
Date of Birth 
Medicaid # 
 
SECTION 2 – HEALTHCARE PROVIDER  INFORMATION 
 
Requesting Agency 
Provider’s Specialty 
NPI # 
 
 
 
Contact Name 
Phone # 
Fax # 
Previous Authorization # 
 
Referring Physician   
Phone # 
Fax # 
 
 
Diagnosis Codes 
Service Dates 
 
SECTION 3 – SERVICE INFORMATION
 
Type of Request 
☐ 
☐ 
 
 
New Request   
 
 
 
Extension Only 
Number Approved
Type of Service 
# of Visits 
Dates(s) 
 
(For Riverside health Use Only)
☐ 
 
Skilled Nursing Visits 
 
 
PT Visits 
☐ 
 
OT Visits 
☐ 
 
ST Visits 
☐ 
 
MSW Visits 
☐ 
 
Home Hospice Visits 
☐ 
 
Private Duty Visits 
☐ 
 
Infusion Visits 
Other ____________   
 
SECTION 4 – OTHER INSURANCE INFORMATION
 
Primary Insurance (if applicable)            
Group#
 
 
DO NOT WRITE BELOW THIS LINE  
(For Riverside Health Use Only) 
 
Authorization # 
Dates Approved 
If you need to speak to a Utilization Management Representative, call 1-800-730-8543. 
 
SERVICES ARE NOT CONSIDERED AUTHORIZED UNTIL RIVERSIDE HEALTH ISSUES AN APPROVAL 
HS.UM.15
MAY PHOTOCOPY FOR OFFICE USE
 

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