MA Home Care Technical Change Request

Complete and submit this form to request a technical change to an existing approved home care (non-PCA) service authorization for your agency.

DHS will not process requests that:

increase overall services (unless another provider already submitted a release of units)
increase dates not in the original service authorization

Submit requests for initial authorization, increases or additional dates of service to the medical review agent.

For use by providers of Home Health Aide (HHA), Skilled Nurse Visits (SNV) or Home Care Nursing (HCN) services only.

Service agreement

CHANGE/START DATE

END DATE

LAST NAME

FIRST NAME

8 Digit MEMBER ID (also known as PMI number)

DATE OF BIRTH

NAME OF PERSON WHO SIGNED RELEASE

DATE OF SIGNATURE

RELATIONSHIP TO MEMBER (if member is their own responsible party, enter self)

As the provider, I have received/maintained the signature of the responsible party requesting this change.

PROVIDER NAME

PROVIDER NPI or UMPI

Are you a consolidated provider?

Yes

TAXONOMY CODE

I don't know my taxonomy code (provider type and address required)

PROVIDER TYPE

FULL ADDRESS

NAME OF REQUESTOR

TITLE OF REQUESTOR

PHONE NUMBER