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The form also records ordering provider and performing agency information with billing and identifiers such as NPI and tax ID, plus fax and phone contacts when needed. It includes an expedite request section requiring physician justification and a signature, and instructs faxing the completed authorization with supporting clinical documentation.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/home-health-services-request-form-fax-authorization/288816/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/home-health-services-request-form-fax-authorization/288816.png","ImageObject",442,249,{"name":88,"@type":89},"Terk","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-12","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":15},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Who should complete the Home Health Services Request Form?","Question",{"text":108,"@type":109},"A submitter provides patient and authorization details, and ordering provider and performing agency sections collect provider and facility information.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What information is required for service details?",{"text":113,"@type":109},"Service details include the type of care, place of service, start date and end date, plus requested visit counts and related CPT/HCP information.",{"name":115,"@type":106,"acceptedAnswer":116},"How does an expedite request work on the form?",{"text":117,"@type":109},"The physician (or other clinician) must indicate that standard timeframes could seriously jeopardize the patient’s life or health or ability to regain maximum function, and must provide justification and a signature. If the service date is more than 3 days in the future, do not submit as expedited.","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},288816,1791340765,{"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":15,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":47,"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":73},1099525198933,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","# Home Health Services Request Form\n\nStill faxing?If so,you may be missing out on timesaving benefits,including automatic approvals and guided submissions only available when usingthe Cohere portal to manage authorizations.Registration only takes a few minutes,and unlocks access for all users at your practice organization.Visit www.coherehealth.com/register to begin.  \n\n| Patient information   | First name *required   |  |  |  |  |  |  |  |  |  |  |  | Last name *required   |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n|  | Member ID *r   |  |  | equir   | ed   |  |  |  |  |  |  |  | Dat   | e of b   | irth(  \u003Cbr>/   | MM/D   | D/Y   | YYY)  \u003Cbr>/   | *req   | uired   |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Submitter information   | Submitter first name *required   |  |  |  |  |  |  |  |  |  |  |  | Submitter last name *required   |  |  |  |  |  |  |  |  |  |  |  |\n|  | Submitter email *required if phone number not provided   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  | Submitte   |  | r fax    | numb  \u003Cbr>一   | er   |  |  | 一   |  |  |  |  | Sub   | mitte   | r pho   | ne nu  \u003Cbr>一   | mbe   | r *re   | quire   | d if e  \u003Cbr>一   | mail n   | ot pr   | ovide   | d   |\n| Diagnosis   | Primary d   |  | iagn   | osis c  \u003Cbr>·   | ode    | *req   | uired   |  | Sec   | onda   | ry dia   | gno   | sis co   | de   |  |  | Sec   | onda   | ry dia   | gnos  \u003Cbr>·   | is co   | de   |  |  |\n| Service details   | Star   | t Dat   | e(M  \u003Cbr>/   | M/DD   | /YYY   | Y)*r  \u003Cbr>/   | equir   | ed   |  |  |  |  | End    | Date   | (MM  \u003Cbr>/   | /DD/   | YYYY   | )*re  \u003Cbr>/   | quire   | d   |  |  |  |  |\n|  | Type of care(Choose one)*required  \u003Cbr>○ Home Health *enter number of visits per requested service below  \u003Cbr>O Hospice   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  | Place of service(Choose one)*required  \u003Cbr>O10-Telehealth in the Home  \u003Cbr>○12-Home  \u003Cbr>○13-Assisted Living Facility  \u003Cbr>○14-Group Home  \u003Cbr>○32-Nursing Facility  \u003Cbr>○Other______   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n\n\n| Home Health    | Aide  \u003Cbr>visits   | Physical    |  | Thera   | py  \u003Cbr>visits   | Skilled N   | ursing   | visits   |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Medical Socia   | l Services  \u003Cbr>visits   | Occ   | upat   | ional    | Therapy  \u003Cbr>visits   | Speech/L   | anguage Therapy  \u003Cbr>visits   |  |\n\n\n| CPT/HCP   | CS *   | requ   | ired   |  | CPT   | /HCP   | CS   |  |  |  | CPT   | /HCP   | CS   |  |  |  | CPT   | /HC   | PCS   |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nContinued on following page  \nThe information transmitted is intended only for the person or entity to which it is addressed and may contain CONFIDENTIAL material.If you receive thismaterial/information in error,please contact the sender and delete or destroy the material/information.  \nGeisinger Health Plan is part of Geisinger,an integrated health care delivery and coverage organization.Geisinger may refer collectively to health carecoverage sponsors Geisinger Health Plan,Geisinger Quality Options,Inc.,and Geisinger Indemnity Insurance Company,unless otherwise noted.GeisingerHealth Plan Medical Management retains decision-making authority on all requests.  \nHome Health Services Request Form  \nGeisinger  \nComplete and fax this authorization request form,including supporting clinical documentation to(570)271-5507.  \n\n| Ordering provider   | Name *required   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n|  | Billing street","cbCaicIzKBOYanLU","https://ap.wps.com/l/cbCaicIzKBOYanLU","pdf",3385480,"English","# Patient information\n## Submitter information\n## Diagnosis\n## Service details\n## Home Health visit counts\n## CPT/HCP codes\n## Ordering provider\n## Performing agency\n## Expedite request","[{\"question\":\"Who should complete the Home Health Services Request Form?\",\"answer\":\"A submitter provides patient and authorization details, and ordering provider and performing agency sections collect provider and facility information.\"},{\"question\":\"What information is required for service details?\",\"answer\":\"Service details include the type of care, place of service, start date and end date, plus requested visit counts and related CPT/HCP information.\"},{\"question\":\"How does an expedite request work on the form?\",\"answer\":\"The physician (or other clinician) must indicate that standard timeframes could seriously jeopardize the patient’s life or health or ability to regain maximum function, and must provide justification and a signature. If the service date is more than 3 days in the future, do not submit as expedited.\"}]","Home Health Services Request Form - Fax Authorization | PDF",1789634003]