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.