3545 N.W. 58th St., Ste. 600, Oklahoma City, OK 73112
Phone: 405-717-8879 or 800-543-6044, ext. 8879
Fax: 1-405-949-5459 or 1-405-949-5501

HOME HEALTH REQUEST

This form must be completed and accompany all requests. Incomplete forms will not be reviewed.


 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes            No      

# 1 most recent clinical note must accompany request:


PLEASE LIST TOTAL # OF SERVICES AND FREQUENCY REQUESTED FOR EACH SPECIALTY (EX: 1 W 1, 2 W 2)


SNV        Frequency:        W     ,        W    
 
PT        Frequency:        W     ,        W    
 
OT        Frequency:        W     ,        W    
 
ST        Frequency:        W     ,        W    

 


# 2 most recent clinical note must accompany request:


PLEASE LIST TOTAL # OF SERVICES AND FREQUENCY REQUESTED FOR EACH SPECIALTY (EX: 1 W 1, 2 W 2)


SNV        Frequency:        W     ,        W    
 
PT        Frequency:        W     ,        W    
 
OT        Frequency:        W     ,        W    
 
ST        Frequency:        W     ,        W    

 


# 3 most recent clinical note must accompany request:


PLEASE LIST TOTAL # OF SERVICES AND FREQUENCY REQUESTED FOR EACH SPECIALTY (EX: 1 W 1, 2 W 2)


SNV        Frequency:        W     ,        W    
 
PT        Frequency:        W     ,        W    
 
OT        Frequency:        W     ,        W    
 
ST        Frequency:        W     ,        W    

 
 


** All information is required for review. Information provided is private and confidential. **

NOTE: These benefits are applicable only if the patient is an eligible enrolled member of a HealthChoice plan. All benefits are subject to the deductible, coinsurance and policy provisions. Please verify benefits and eligibility by calling the medical claims administrator toll-free at 800-323-4314.

MEDICARE PATIENTS: If HealthChoice provides coverage that is supplemental to Medicare, all requested services must be approved by Medicare. The Medicare EOB should be filed for claims processing.