Get Beneficiary Elected Transfer Form

This guide will assist you in completing the Beneficiary Elected Transfer Form online. By following these straightforward steps, you will ensure that the transfer of home health services is executed correctly and efficiently.

Follow the steps to complete the Beneficiary Elected Transfer Form.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Begin by entering the name of the patient in the designated field. Ensure that you provide the full legal name for accuracy.
3. Next, fill in the complete address of the patient. This should include the street address, city, state, and ZIP code.
4. In the next section, write your own name as the individual electing Pacific Home Health Care, Inc. for services. Make sure to match the format requested.
5. Indicate the name of the previous home health agency in the provided field. This informs whom you are transferring from.
6. You will need to acknowledge your understanding of the change by signing in the designated area. Both the patient or responsible party must provide the relationship.
7. Lastly, include the date when you are filling out the form in the appropriate section. Once you have reviewed all input for correctness, save your changes.
8. You can now download, print, or share the form as needed.

Complete your documents online to ensure a smooth transition of care.