Nursing care form 2026

1. Click ‘Get Form’ to open the Skilled Home Private Duty Nursing Care Precertification Information Request Form in the editor.
2. Begin by filling out Section 1 with general information about the member, including their name, administrative reference number, and date of birth.
3. In Section 2, provide patient-specific information. Indicate whether this is an initial request or an extension, and detail the patient's home care needs and living situation.
4. If applicable, complete Section 3 for patients on ventilators by noting the date they became dependent and the hours per day they require support.
5. Gather necessary documentation as outlined in Section 4, including a letter of medical necessity and physician orders.
6. Review Section 5 for important information regarding fraudulent claims before signing in Section 6. Ensure all fields are completed accurately.
7. Once completed, submit your form electronically through our secure provider website or via fax/mail as instructed.

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