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Requires current physician orders, clinical notes, and recent diagnostic documentation, and mandates notification for any date-of-service changes. Includes sections to capture requestor and member demographics, provider and agency details, diagnosis codes, requested services, and discharge planning needs. 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Call the expedited line provided on the form.",{"name":115,"@type":106,"acceptedAnswer":116},"Where should the completed form be faxed?",{"text":117,"@type":109},"Fax the completed form to the state-specific Medicare fax line listed at the bottom of the form, with separate numbers for Medicare-only, dual coverage (Florida/Georgia), and other states.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},288176,1790051483,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":47,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},8796095462418,"https://ap-avatar.wpscdn.com/avatar/80000253c1241d02b47?x-image-process=image/resize,m_fixed,w_180,h_180&k=1778826106357471780","Want faster service? Use our Provider [Portal at](Portal at provider.wellcare.com)[ provider.wellcare.com](Portal at provider.wellcare.com). \nHome Health Authorization Request Form \n*Indicates a required field \nRequirements: Clinical information and supporting documentation should consist of current physician orders, notes, and recent diagnostics. Notification is required for any date-of-service change. \nExpedited Requests: If the standard time to make a determination could seriously jeopardize the life and/or health of the member or the member’s ability to regain maximum function, please call 1-855-538-0454. \n Please fax completed form to appropriate number at bottom of form. \n\n| Requestor Name* : | Fax* : | Phone* : |\n| --- | --- | --- |\n\n\n| Member Information (please print) | | | | | | |\n| --- | --- | --- | --- | --- | --- | --- |\n| Wellcare ID* : | | Medicaid/Medicare ID: | | | | |\n| Last Name* : | | First Name, MI* : | | Date of Birth* :/ / | | |\n| Requesting Provider (please print) | | | | | | |\n| Wellcare ID: | | NPI/Tax ID* : | | | | |\n| Provider Name* : | | Fax* : | | Phone: | | |\n| Address: | | City: | | State: | | ZIP Code: |\n| Home Health Agency (please print) | | | | | | |\n| Wellcare ID: | | NPI/Tax ID* : | | | | |\n| Provider Name* : | | Fax* : | | Phone: | | |\n| Address: | | City: | | State: | | ZIP Code: |\n| Diagnosis Codes* | | | | | | |\n| ICD-10: | ICD-10: | | ICD-10: | | ICD-10: | |\n| \u003Cbr>Requested Services* (please print)\u003Cbr>**PT, OT and other home health services may be delegated to EviCore or Coastal Care. Please check the QRG** | | | | | | |\n| Are services needed for discharge planning? □ Yes □ No Discharge Date: / / | | | | | | |\n\n(continued) \n©Wellcare 2026 5715951_NA6PCARFRME \nInternal Approved 02032026 \n\n| Service Requested* | Procedure | Start Date | End Date | Frequency |\n| --- | --- | --- | --- | --- |\n| Skilled Nursing | | | | days a week for weeks = visits |\n| Home Health Aid | | | | days a week for weeks = visits |\n| MSW (Social Worker) | | | | days a week for weeks = visits |\n| Physical Therapy | | | | days a week for weeks = visits |\n| Occupational Therapy | | | | days a week for weeks = visits |\n| Speech Therapy | | | | days a week for weeks = visits |\n| Episode of Care (Medicare Only) | | | | days a week for weeks = visits |\n\n Please fax completed form to: \n\n| Medicare Fax Lines | |\n| --- | --- |\n| Connecticut: 1-866-455-6529 | Kentucky: 1-888-361-5684 |\n| Florida Medicare only: 1-877-892-8216 | New Jersey: 1-877-892-8221 |\n| Georgia Medicare only: 1-877-892-8213 | New York: 1-877-892-8214 |\n| Florida/Georgia Dual: 1-877-277-1820 | Texas: 1-877-894-2034 |\n| Illinois: 1-877-899-2044 | All others: 1-888-361-5684 |\n\n[wellcare.com](wellcare.com)","cbCaifvCJVvyp1CU","https://ap.wps.com/l/cbCaifvCJVvyp1CU","pdf",92048,"English","# Request Requirements\n## Expedited Requests\n# Requestor and Member Information\n# Provider and Home Health Agency Details\n# Diagnosis Codes and Requested Services\n## Discharge Planning\n# Services Schedule and Medicare Episode of Care\n# Fax Submission by State","[{\"question\":\"What documents are required with the home health authorization request?\",\"answer\":\"The form requires current physician orders, clinical notes, and recent diagnostics/supporting documentation. It also requires notification for any date-of-service change.\"},{\"question\":\"When should an expedited request be used?\",\"answer\":\"Use expedited requests when the standard determination timeline could seriously jeopardize the member’s life, health, or ability to regain maximum function. Call the expedited line provided on the form.\"},{\"question\":\"Where should the completed form be faxed?\",\"answer\":\"Fax the completed form to the state-specific Medicare fax line listed at the bottom of the form, with separate numbers for Medicare-only, dual coverage (Florida/Georgia), and other states.\"}]","Home Health Authorization Request Form | PDF",1789633201]