Home Care Services Step 1 of 4 25% Member InformationEnter Member Id and Date of Birth to validate Member before proceeding with the form.Member's ID#* Date of Birth* MM slash DD slash YYYY Start Date* MM slash DD slash YYYY End Date* MM slash DD slash YYYY Member's Name* First Last Error Message Facility InformationHome Care Agency NPI* Home Care Agency Name* Error Message Phone #*Fax #*Contact Name* Email address in order to receive confirmation of request receipt* Clinical InformationOrdering MD Ordering MD Phone #Diagnosis (Click + or - at the right to add up to 5 Diagnoses)*DiagnosisICD 10 Diagnosis Code Example ICD 10 Diag Code: Z87.890Please Choose Serviceselect all that apply Section A - RN Initial Assessment and/or Home Health Care Service and/or T1001 Regulatory assessment Section B - Integrity Combo- Homemaker services Section C - HHA/CNA/RN long term hours Section ARN Initial Assessment and/or Home Health Care Service and/or T1001 Regulatory assessmentType of Service Requested*Please note: if HHA/CNA must utilize S5125 RN/LPN HHA/CNA PT OT ST MSW HCPC / S Codes and 2 digit modifier / CPT Codes (RN/LPN)*Code TypeCodeUnits Example HCPC code: S1234 with modifier: S1234 U1 Example S code: SA Example CPT code: 12345Start Date (RN/LPN)* MM slash DD slash YYYY End Date (RN/LPN)* MM slash DD slash YYYY HCPC / S Codes and 2 digit modifier / CPT Codes (HHA/CNA)*Code TypeCodeUnits Example HCPC code: S1234 with modifier: S1234 U1 Example S code: SA Example CPT code: 12345Start Date (HHA/CNA)* MM slash DD slash YYYY End Date (HHA/CNA)* MM slash DD slash YYYY HCPC / S Codes and 2 digit modifier / CPT Codes (PT)*Code TypeCodeUnits Example HCPC code: S1234 with modifier: S1234 U1 Example S code: SA Example CPT code: 12345Start Date (PT)* MM slash DD slash YYYY End Date (PT)* MM slash DD slash YYYY HCPC / S Codes and 2 digit modifier / CPT Codes (OT)*Code TypeCodeUnits Example HCPC code: S1234 with modifier: S1234 U1 Example S code: SA Example CPT code: 12345Start Date (OT)* MM slash DD slash YYYY End Date (OT)* MM slash DD slash YYYY HCPC / S Codes and 2 digit modifier / CPT Codes (ST)*Code TypeCodeUnits Example HCPC code: S1234 with modifier: S1234 U1 Example S code: SA Example CPT code: 12345Start Date (ST)* MM slash DD slash YYYY End Date (ST)* MM slash DD slash YYYY HCPC / S Codes and 2 digit modifier / CPT Codes (MSW)*Code TypeCodeUnits Example HCPC code: S1234 with modifier: S1234 U1 Example S code: SA Example CPT code: 12345Start Date (MSW)* MM slash DD slash YYYY End Date (MSW)* MM slash DD slash YYYY Section BIntegrity Combo- Homemaker servicesPlease submit initial Skilled Nurse AssessmentPlease choose service* S5125 U1 Combo Services:Personal care and homemaking services performed by a HHA/CNA during the same session (per 15 min) S5125 U1 U9 Combo Services High Acuity: Personal care and homemaking services performed by a HHA/CNA during the same session (per 15 min) Please note: you must complete the MDS form if choosing this option S5130 Homemaker Services: Provided by a homemaker or HHA/CNA during the same session (per 15 min) Number of hours / week*Please enter a number from 0 to 168.Units / week*Please enter a number from 0 to 1000.Start Date* MM slash DD slash YYYY End Date* MM slash DD slash YYYY Section CHHA/CNA/RN long term hoursPlease submit initial/recent Skilled Nursing AssessmentPlease choose service being requested*Please choose service being requested *HHA/CNA S5125Skilled NursingHCPC / CPT Codes*Code TypeCodeUnits Example HCPC code: S1234 with modifier: S1234 U1 Example CPT code: 12345Number of hours / week*Please enter a number from 0 to 168.Units / week*Please enter a number from 0 to 1000.Start Date* MM slash DD slash YYYY End Date* MM slash DD slash YYYY Attach Clinical* Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 10 MB, Max. files: 10. Upload only PDF or Word DocumentSignature of Physician or Licensed Provider (Required for skilled service)*Signature Date:* Consent* Per EOHHS, Neighborhood cannot pay for services provided by individuals legally responsible for the member. By checking this box you are attesting that contracted services provided to this member will not be rendered by a person that is legally responsible for the memberRequest Method*Request Method *StandardExpedited: By checking Expedited, you are stating that processing this request in the standard time (14 days) for making a determination could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function. Please attach documentation that supports the need for an Expedited decision. Also please note that a request with a date of service in the past cannot be considered as Expedited.Attach additional Clinical documents for Expedited request*Accepted file types: pdf, doc, docx, Max. file size: 13 MB.Upload only PDF or Word DocumentsSignature of Physician or Licensed Provider (Required for Expedited request)*Signature Date:* CommentsAuthorization is not a guarantee of paymentCAPTCHAConsent I agree to the privacy policy.