Get Hfs 1409

The HFS 1409 form is a crucial document required for prior approval requests related to home health therapy services. This guide provides a comprehensive overview and step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to successfully complete the HFS 1409 form.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Enter the recipient ID number, a nine-digit identifier assigned to the patient for whom the service or item is requested.
3. Fill in the recipient name, providing the full name of the patient related to the request.
4. Input the patient’s birth date in the provided field.
5. Type the provider number as indicated on the Provider Information Sheet.
6. Enter the telephone number of the provider’s office to facilitate further communication if needed.
7. Provide the name of the provider who will be responsible for delivering the service or item.
8. Input the name of the physician or other provider who signed the order recommending the specific service or item.
9. Enter the street address of the provider's office.
10. Fill in the street address of the ordering practitioner.
11. Complete the city, state, and ZIP code fields for both the provider and physician.
12. Enter the diagnosis code using ICD-9-CM or ICD-10, relevant to the patient’s condition.
13. If applicable, add any additional diagnosis codes that pertain to the request.
14. Provide a brief description corresponding to the diagnosis code mentioned earlier.
15. Include the patient’s height and weight, which are necessary for durable medical equipment requests.
16. Input the procedure code that specifies the item or service being requested.
17. Briefly describe the services or items to be provided, detailing specifics if necessary.
18. Indicate the quantity of items requested or the frequency of the services needed.
19. Enter the two-digit category of service code corresponding to the requested item or service.
20. Fill in the total charge for the item being requested; leave the approved HFS amount blank.
21. Provide the begin and end date of the service if applicable.
22. If necessary, use the additional fields for more procedures or medical necessities.
23. Make sure the provider signs and dates the form, as required.
24. After reviewing the form for completeness and accuracy, save changes and download, print, or share the form as needed.

Complete the HFS 1409 form online today for a streamlined approval process.