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Get CMS-10280 2013-2024

If you don t agree with this change discuss it with your home health agency or the doctor who orders your home care. Home Health Agency Patient Name Address Patient Identification Phone Home Health Change of Care Notice HHCCN Your home health care is going to change. Starting on date will change the following items and/or services for the reasons listed below. Items/services Reason for change Read the information next to the checked box below. Your home health agency is giving you this information because Your doctor s orders for your home care have changed. The home health agency must follow physician orders to give you care. Starting on date will change the following items and/or services for the reasons listed below. Items/services Reason for change Read the information next to the checked box below. Your home health agency is giving you this information because Your doctor s orders for your home care have changed* The home health agency must follow physician orders to give you care. You can look for care from a different home health agency if you have a valid order for home care and still think you need home care. If you need help finding a different home health agency to give you this care contact the doctor who If you get care from a different home health agency you can ask it to bill Medicare. If you have questions about these changes you can contact your home health agency and/or the doctor who orders your home care. You cannot appeal to Medicare about payment for the items/services listed above unless you both receive them and a Medicare claim is filed* Additional Information Please sign and date below to show that you received and understand this notice. Return this signed notice to your home health agency in person or by mailing it to them at the address listed at the top of this notice. Signature of the Patient or of the Authorized Representative Date If a representative signs for the beneficiary write rep or representative next to the signature. If the representative s signature is not clearly legible the representative s name must be printed* Form CMS-10280 Approved 06/2013 OMB Approval No* 0938-1196. You can look for care from a different home health agency if you have a valid order for home care and still think you need home care. If you need help finding a different home health agency to give you this care contact the doctor who If you get care from a different home health agency you can ask it to bill Medicare. If you need help finding a different home health agency to give you this care contact the doctor who If you get care from a different home health agency you can ask it to bill Medicare. If you have questions about these changes you can contact your home health agency and/or the doctor who orders your home care. If you have questions about these changes you can contact your home health agency and/or the doctor who orders your home care. You cannot appeal to Medicare about payment for the items/services listed above unless you both receive them and a Medicare claim is filed* Additional Information Please sign and date below to show that you received and understand this notice. .

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