HOME HEALTH CARE Re-AUTHORIZATION REQUEST FORM 2025

1. Click ‘Get Form’ to open the HOME HEALTH CARE Re-AUTHORIZATION REQUEST FORM in the editor.
2. Begin by entering the 'Date of Request' at the top of the form. This is essential for tracking your request.
3. Fill in the 'Member Name' and 'DOB' fields accurately to ensure proper identification.
4. Select the type of request: Standard, Retro, or Urgent. If you choose Urgent, provide a justification as it requires special handling.
5. Complete the 'Agency' and 'NPI' sections, ensuring that all required information is provided for processing.
6. In the diagnosis section, list all relevant codes and descriptions for Primary, Secondary, Tertiary, and Quaternary diagnoses.
7. Review the REQUIRED CHECKLIST at the bottom of the form to ensure you have included all necessary documentation before submission.

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