Re-Authorization Form

Please fill out form to submit your Re-Authorization request

HOME HEALTH CARE REQUEST RE-AUTHORIZATION FORM

Questions? Call (888) 705-5274

If you are submitting additional documents in regards to a previous re-authorization request, please complete the required fields and scroll down to the Additional Information section. 


Patient and Clinician Information


Additional Visits

Add visits for a discipline already in the home




Please complete if request is for Wound Care

*** Must include current measurements and color wound photos ***


Additional Discipline

Add check for discipline(s) that are NOT already in the home


Comments

Please enter any comments


RA notification to agency confirms receipt of determination with approved visits. Should you disagree with approval, please notify PHCN UM Department at (888) 705-5274. Should a material change in member status occur, submit an additional request with pertinent clinical documentation.