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F11096 2026
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- Click ‘Get Form’ to open the f11096 in the editor.
- Begin with SECTION I — MEMBER INFORMATION. Fill in the member's name, telephone number, identification number, start of care date, and certification period.
- Move to SECTION II — PERTINENT DIAGNOSES AND PROBLEMS TO BE TREATED. Enter the principal diagnosis along with its ICD code and date of diagnosis. Include any surgical procedures and other pertinent diagnoses.
- In SECTION III — BRIEF MEDICAL AND SOCIAL INFORMATION, provide details on durable medical equipment, functional limitations, activities permitted, medications, allergies, nutritional requirements, mental status, and prognosis.
- Proceed to SECTION IV — ORDERS. Document orders for services and treatments along with goals and discharge plans.
- Complete SECTION V — SUPPLEMENTARY MEDICAL INFORMATION by filling in current information about the member’s home environment and any relevant medical reasons for leaving home.
- Finally, ensure all signatures are completed in SECTION VI before saving your form.
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PRIOR AUTHORIZATION / CARE PLAN ATTACHMENT (PA/CPA). Instructions: Print or type clearly. Refer to the Required Information for Prior Authorization/CareRead more