Home Health Care Form Tennessee/n Georgia/n Mississippi

 

TENNESSEE/N GEORGIA/N MISSISSIPPI

HOME HEALTH CARE FORM

 

844-411-9622

PLEASE FAX THIS FORM ALONG WITH REQUIRED INFORMATION TO:

844-411-9621

Questions? Call

Standard   R equest      

Urgent   R equest  

Request Type

48   h ours    

By   signing   below,   I  

Please Read if Urgent Request:

 

certify   that   waiting   for   a   decision   under   the  

Date:

standard   time   frame   could   place   the   enrollee’s   life,  

Retro   R equest    

health,   or   ability   to   regain   maximum   function   in  

Urgent   Requests   may   take  

serious   jeopardy.    

Retro   R equests   m ay   t ake   u p   t o   3 0   d ays   r eview.  

up   t o   2 4   h ours

 

If   y ou   h ave   r eceived   a   d enied   c laim-­‐   p lease  

submit   c linical   i nformation   t hrough   a ppeals.

Signature:

_____________________________

Member   N ame:

 

Provider  

N ame:  

DOB:  

NPI#  

Member   I D#:      

New   R equest     o r     A dditional   V isits:  

Contact   N ame:  

Post   H ospital   D ischarge?     Y es                   D ate:                                         N o

BRANCH:  

 

 

Start   o f   C are   d ate:  

Phone:                                                                                               F ax:  

Auth   #   ( if   a pplicable)  

Diagnosis   ( incl   C odes)

Ordering   M D:

HOMEBOUND STATUS :    

Y es  

No    

CMS   D efined

:  Homebound   s tatus   c ertified   b y   M D,   l eaving   t he   h ome   i s   a  

considerable   a nd   t axing   e ffort,   i nfrequent   a nd   s hort   d uration   o r   a re   a ttributable   t o   r eceive   h ealth   c are   t reatment.  

What   i s   B eing   R equested  

#   O f   v isits  

Frequency   o f   v isits  

Reason   f or   v isits  

( place  

( incl.  

( i.e.  

dates   o f   s ervice   b eside   e ach  

for   a ll   d isciplines  

3w2,   i ncl.   f or   a ll   d isciplines  

(please   a ttach   c urrent   c linical  

 

discipline   y ou   a re   r equesting)  

requested)  

requested)

related   t o   r eason)  

Skilled   N ursing  

 

 

( incl.   w ound  

Wound   C are  

□

measurements,   n ame/dosage  

Foley  or   P EG   c are  

□

frequency   o f   m edications   i f   a ppl.)  

Access   C are   ( port/PICC)  

□

 

Teaching/Compliance    

□

 

Injections/Infusion  

□

Other:  

□

PT  

 

 

( all   t herapy   r equests   s hould  

Home   A ssessment  

□

include   c urrent   l evel   o f   f unction   a nd  

Exercise/Strengthening  

□

goals)  

AD/Equipment  Training  

□

 

Energy   C onservation    

□

Home   E xercise   P rogram  

□

Other      

Safety              

□

□

Strengthening  

OT  

 

 

□

Safety            

Other

 

□

□

ST  

 

 

Other  

Communication    

□

□

Cognitive      

Swallowing  

□

□

HHA  

 

 

Assist   w ith   A DL’s  

□

Functional   i mpairment  

□

Other:  

□

MSW  

 

 

 

Able/willing/teachable  

 

D/C   P lan   ( discharge   p lanning   b egins   a t   a dmission,   v isits  

approved   m ay   i nclude   2   v isits   t o   i ssue   N OMNC):    

caregiver?  

I f   n o,   p lease   e xplain