Home Health Care Pre-Authorization Request Form
Patient Information
Patient Name
Date of Birth
Member ID
Address
Phone Number
Provider Information
Referring Physician Name
NPI Number
Phone
Fax
Email
Requested Home Health Care Services
Service Type
Skilled Nursing
Physical Therapy
Occupational Therapy
Speech Therapy
Home Health Aide
Medical Social Services
Other
Requested Start Date
Frequency/Duration
Diagnosis/ICD-10 Code(s)
Primary Diagnosis
ICD-10 Code
Secondary Diagnosis
ICD-10 Code
Clinical Information
Reason for Home Health Care
Recent Hospitalization/Facility Stay (if applicable)
Other Relevant Clinical Information
Requesting Provider Signature
Name
Date