Get Hba Form

The Hba Form is an essential document for individuals who have received a notice from MassHealth regarding the demand-billing of Medicare for home health agency services. This guide provides a clear and user-friendly approach to completing the form online, ensuring that all necessary information is accurately submitted.

Follow the steps to complete the Hba Form online:

1. Press the ‘Get Form’ button to obtain the Hba Form and open it in your preferred editor.
2. In Section I, provide the required details including the provider's name, patient's name, dates of service, MassHealth Provider ID, and MassHealth Member ID.
3. In Section II, check one or more boxes to describe why the patient is not considered homebound as defined by the Social Security Act. If necessary, provide additional reasons under the 'Other' option.
4. In Section III, attach copies of relevant clinical records that support the assertion that the patient is not homebound. Select the type of documentation you will attach, or specify under 'Other' if not listed.
5. In Section IV, include any additional information pertinent to the patient's homebound status. If the documentation you provide fully describes this status, you may leave this section blank.
6. In Section V, complete the provider attestation by signing and dating the form. Ensure the printed legal name of the provider and the individual signing on behalf of a legal entity are included.
7. Once you have filled out the form, save your changes, download the completed document, or prepare it for printing.
8. Follow the instructions in Section VI regarding submitting the Homebound Assessment Form via secure e-mail or secure FTP connection to MassHealth.

Complete your Hba Form online today to ensure accurate and timely processing.