Home Health Services Request Form - Geisinger 2025

1. Click ‘Get Form’ to open the Home Health Services Request Form in the editor.
2. Begin by selecting the type of request you are making: Home Health, Hospice, Infusion Therapy, Concurrent Therapy, or Initial Therapy. This will guide the rest of your form completion.
3. Fill in the Authorization Number and Requested Services fields. Specify which services are needed by checking the appropriate boxes for SN, PT, PTA, OT, OTA, ST, HHA, and MSW.
4. Provide Member Information including Member Name, Date of Birth (DOB), and Member ID. Ensure accuracy as this information is crucial for processing.
5. Complete the Referral Source section by entering the Referring Provider Name and Agency Information such as Provider Name and GHP Provider ID #.
6. Input relevant dates including Start of Care, Tenth Visit Completion Date, Date of Discharge from Previous Episode of Care, and Resumption of Care Date if applicable.
7. Indicate the Number of Visits Used for each service requested. Lastly, specify if a caregiver is available to assist and where the member lives.

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