HOME HEALTH CARE AGENCY

SERVICE REQUEST FORM

Submit Complete Form to AvMed’s Pre-Authorization Department: Fax 1-800-552-8633 / Link Line: 1-800-816-5465

Date of Request: Initial Episode Period Subsequent Episode

AvMed MEMBER Last, First Names: AvMed ID #: A Date of Birth: AvMed Case Manager (circle choice): Yes No Unknown Name of AvMed Case Manager:

HOME HEALTH CARE AGENCY Agency Name: Provider ID #: Phone: Fax: Contact Person:

REQUESTING PHYSICIAN Name: Provider ID #: Phone: Fax: Contact Person:

DIAGNOSIS INFORMATION ICD9 (Diagnosis Code[s]) Diagnosis Description

SUMMARY OF CLINICAL DATA JUSTIFYING “REASONABLE & NECESSARY” STATUS Please submit clinical documentation below:

TYPE OF SERVICES REQUESTED RN: Care/services to be rendered (specify in detail): 1. Evaluation Request: 2. Additional Services: CPT Code: CPT Code: CPT Description: CPT Description: From (date): From (date): To: To (date): Total # weeks: Total # visits per week:

Medical Department Procedure 01.023 Attachment A Revised (1/08) Page 1 of 3

Member Name: ID: A Date of Request: Agency:

LPN: Care/services to be rendered (specify in detail): CPT Code: CPT Description: From (date): To (date): Total # weeks: Total # visits per week:

Physical Therapist: Care/services to be rendered (specify in detail):

1. Evaluation Request: 2. Additional Services: CPT Code: CPT Code: CPT Description: CPT Description: From (date): From (date): To: To (date): Total # weeks: Total # visits per week:

Occupational Therapist: Care/services to be rendered (specify in detail): 1. Evaluation Request: 2. Additional Services: CPT Code: CPT Code: CPT Description: CPT Description: From (date): From (date): To: To (date): Total # weeks: Total # visits per week:

Speech Therapist: Care/services to be rendered (specify in detail):

1. Evaluation Request: 2. Additional Services: CPT Code: CPT Code: CPT Description: CPT Description: From (date): From (date): To: To (date): Total # weeks: Total # visits per week:

Home Health Aide: may only be requested in correlation with, and during the same timeframe as, authorized professional services. Care/services to be rendered (specify in detail):

CPT Code: CPT Description: From (date): Total # hours per day: Total # weeks:

Medical Social Worker: Care/services to be rendered (specify in detail):

CPT Code: CPT Description: From (date): Total # hours per day: Total # weeks:

Medical Department Procedure 01.023 Attachment A Revised (1/08) Page 2 of 3

Member Name: ID: A Date of Request: Agency:

ADDITIONAL DOCUMENTATION REQUIRED FOR SUBMISSION: • Clinical documentation: Yes • Agency’s Plan of Care: Yes • Optional Supporting documentation: Yes No ATTESTATION: I hereby acknowledge that the data submitted on this form accurately represents information submitted to the Agency by the requesting independent practitioner: • The detailed, written, and signed orders of the treating physician -OR- the optional Physician Request for Home

Health Care Services (for Commercial Members); OR

• The required CMS Physician Certification (for Medicare Members); AND

• The services are “reasonable and necessary” as supported by clinical documentation; • Member is “confined to home”; • Service is requested on an “intermittent/part-time” basis; • Home Health Aide services, if indicated, are specifically requested in writing and are to be rendered in correlation

with, and during the same timeframe as, authorized professional services.

Agency Clinical Representative (print name, title) Signature of Agency Clinical Representative Title: Date:

Medical Department Procedure 01.023 Attachment A Revised (1/08) Page 3 of 3