re-authorization Form

Please fill out form to submit your Re-Authorization request.

home health care request re-authorization form

Questions? Call (888) 705-5274

If you are submitting additional documents in regards to a previous re-authorization request, please complete the required fields and scroll down to the Additional Information section.

    Date of Request*
    Current Certification Period*
    Agency Name*
    Agency NPI*
    Contact First Name*
    Contact Last Name*
    Agency Fax*
    Agency Phone*
    Agency Email*
    Approved Authorization Return Preference*

    patient and clinician information



    Patient First Name*
    Patient Last Name*

    Patient Date of Birth*
    Patient State of Residence*
    Patient Zip Code*
    Physician First Name*
    Physician Last Name*

    Physician Phone
    Physician NPI

    additional visits

    Add visits for the member's home health admission.

    Current Authorization Date Range

    SN Visits:
    PT Visits:
    OT Visits:

    ST Visits:
    MSW Visits:
    HHA Visits:

    Extend to Next Date Range

    SN Visits:
    PT Visits:
    OT Visits:

    ST Visits:
    MSW Visits:
    HHA Visits:

    please complete if request is for wound care

    Must include current measurements and color photos of wound.


    Start Date of Wound:
    Wound Care

    Summary

    additional discipline

    Add check for discipline(s) that are NOT already in the home.

    comments

    Please enter any comments below.

    file upload

    Please upload any necessary files here.

    Submitted By*
    Submitted Date*
    RA notification to agency confirms receipt of determination with approved visits. Should you disagree with approval, please notify tango UM Department at (888) 705-5274. Should a material change in member status occur, submit an additional request with pertinent clinical documentation.