Get Homebound Form

This guide provides detailed instructions for completing the Homebound Form online. Users of various experience levels can follow these steps to ensure that all necessary information is accurately submitted.

Follow the steps to fill out the Homebound Form accurately.

1. Press the ‘Get Form’ button to access the Homebound Form and open it in your preferred online editor.
2. Begin by filling out Section I with the required information: Provider Name, Patient Name, Dates of Service, MassHealth Provider ID, and MassHealth Member ID. Ensure all fields are completed, as incomplete forms will not be accepted.
3. In Section II, check one or more statements that explain why the patient is not homebound according to the outlined legal definitions. If none of the listed options apply, please provide a brief explanation in the 'Other' section.
4. Attach any relevant clinical records in Section III that support the claim regarding the patient's homebound status. Select the appropriate type of documentation from the provided list. If your document type is not listed, choose 'Other' and describe the document in the space provided.
5. Use Section IV to offer any additional information that may be pertinent to the patient’s homebound status. This field can be left blank if the supporting documentation sufficiently explains the situation.
6. In Section V, provide your certification and signature as the provider. Ensure that you complete the date and printed legal names accurately, as only an authorized provider's signature is acceptable.
7. Once you have completed the form, save your changes and download the document. You may also print or share the form as needed.

Complete your Homebound Form online today to ensure timely processing.