Home Health Request For Certification Form - Blue Cross Blue Shield Of Alabama
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1Home Health Services
REQUEST FOR CERTIFICATION*
An Independent Licensee of the Blue Cross and Blue Shield Association
Home Health Services prior to start of care
* Please verify Contract Benefit Information before submission of form *
_____________________________________________________
_______________________
AGENCY
CONTACT
____________________________________________________
______________________
ADDRESS
PROVIDER #
__________________________________________
____________________________________
TAX ID
PHONE #
_____________________________________
____________________________________
ORDERING MD
PHONE #
___________________________________________________________________________________
ADDRESS
PATIENT INFORMATION
_________________________________________________________________________________
Patient Name
________________________________________________________________________________
Patient Address
________________________________________
________________________________
Patient Telephone
DOB
___________________________________________________________________
Primary Caregiver Name and Phone #
__________________________________________________________________________
Primary Contract Number
_____________________________________________________________________________
Secondary Insurance
_____________________________________________ _______________________________
Primary Diagnosis ICD10
_____________________________________________________________________________
Secondary Diagnosis
_______________________________________________________________________________
Initial Start of Care
SERVICES PROVIDED
(indicate all and how often)
From
To
# Visits
Frequency
Authorization #
Initials
RN/LPN
HHA
PT
OT
ST
MSW
________________________
DME: Hospital bed, bedside commode, oxygen/supplies, BIPAP, wheelchair, walker/cane, nutritional supplements, other
___________________________________________________________________________________________________
_____________________________________________________________________
Wound care with measurements and description
_______________________________
CURRENT FUNCTIONAL LEVEL
Homebound
Cognitive
Dressing
Bathing
Toileting
Ambulation
__ Alert and Oriented
__ Independent
__ Independent
__ Independent
__ Independent
__ Impaired
__ Requires Assistance
__ Requires Assistance
__ Requires Assistance
__ Requires Assistance
__ Disoriented
__ Unable
__ Unable
__ Unable
__ Unable
CLINICAL
_____ P
Vital signs:
_____ B/P
_____ R
_____ T
_____ Ht
_____ Wt
_____ BMI
Med/Surg event preceding HH referral ____________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
For all Groups other than General Electric (GE, GEN, GEX), International Paper (IPP), Lowes (LWE), Genuine
Parts (GPT), Wal-Mart (WMR, WLA, WPN, WMZ) and Federal Employees (R) you may fax the completed form to
(205) 402-9305. For inquiries: Birmingham (205) 733-7067, outside Birmingham 1 800 821-7231.
PRO-118-D (Rev. 11-2015)
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