Re-Authorization Form

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 Cert Period

Agency Name

Agency NPI

Contact First Name

Contact Last Name

Agency Fax

Agency Phone

Agency Email

Return Approved Authorization

Fax

Patient and Clinician Information

Patient First Name

Patient Last Name

Patient DOB

Patient State of Residence

Patient Zip Code

Physician First Name

Physician Last Name

Physician Phone

Physician NPI

Additional Visits

Add visits for a discipline already in the home

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 wound photos ***

Summary

Additional Discipline

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

Comments

Please enter any comments

File Upload

Choose File(s) or drag and drop files onto this button

Submitted By

Submitted Date

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