Get Hhc Request Online Form

Filling out the Hhc Request Online Form is an essential step for obtaining necessary home health care services. This guide provides clear, step-by-step instructions to help users navigate through the form efficiently.

Follow the steps to complete the Hhc Request Online Form.

1. Click ‘Get Form’ button to access the form and open it in an editor.
2. Begin by entering the Fidelis Care member's name in the format of Last name, First name, Middle initial.
3. Input the Fidelis Care member ID number to help identify the patient.
4. Fill in the date of birth in the mm/dd/yyyy format for accurate identity verification.
5. Provide the provider information, including their name and title, followed by the address including city, state, and zip code.
6. Enter the provider's phone number, including the area code.
7. Include the provider's tax ID number and National Provider Identifier (NPI) number.
8. Input the provider's fax number, ensuring to include the area code.
9. If applicable, state the IPA affiliation.
10. List the ICD 9 codes and their descriptions pertinent to the patient's condition.
11. Specify the CPT/HCPCS codes and their descriptions for the requested home health care services.
12. Enter the total number of visits requested and confirm if all prior visits have been used by circling YES or NO.
13. If applicable, provide details about previous treatment for the diagnosis and the date of the last treatment.
14. List the quantity under required fields and specify the length of service needed.
15. Indicate any additional supplies or services requested, circling all relevant options such as Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (SP), Home Health Aide (HHA), Medical Social Work (MSW), or Nutritionist.
16. Before finalizing, review all entries in the form to ensure completion and legibility.
17. Once fully completed, save your changes, and then download, print, or share the form as needed.

Start completing your Hhc Request Online Form online today to ensure timely access to necessary services.