Request for Certification - Home Health Services Form - bcbsal 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the AGENCY section, including the contact details, provider number, tax ID, and phone number.
3. Next, complete the ORDERING MD section with the physician's address and phone number.
4. In the PATIENT INFORMATION section, enter the patient's name, address, telephone number, date of birth, contract holder's name, primary caregiver's details, and insurance information.
5. Indicate the services provided by specifying dates, visit frequency, and authorization numbers in the SERVICES PROVIDED section.
6. Assess and document the CURRENT FUNCTIONAL LEVEL of the patient by checking appropriate boxes for cognitive status and daily activities.
7. Finally, record vital signs in the CLINICAL section before submitting your completed form via fax or inquiry as needed.

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