Home Health Services Forms

• Services
• Prior Authorization
• Electronic Visit Verification
• HH Agency Licensure
• FAQs [ 128 kB ]
• Provider Enrollment

Home Health Services

Forms

The following supporting documentation forms are included as appendices to the Florida Medicaid

Home Health Visit Services Coverage Policy [ 268 kB ]

and the Florida Medicaid

Personal Care Services Coverage Policy [ 159.6 kB ]

. Providers must include these forms, incorporated by reference, when requesting authorization for personal care services and with the request for home health aide services for recipients under the age of 21 years, as applicable:

• Parent/Legal Guardian Medical Limitations
• Parent/Legal Guardian School Schedule
• Parent/Legal Guardian Work Schedule
• Parent/Legal Guardian Statement of Work Schedule

According to the Personal Care Services Coverage Policy and the

Private Duty Nursing Services Coverage Policy [ 235.8 kB ]

, providers must maintain the following documentation in the recipient’s file:

• Assessments
• Written physician’s orders
• Plan of care

For provider convenience, these forms are also posted to the

eQHealth Solutions, Inc., website

.

For information on general documentation requirements, please refer to Florida Medicaid’s General Policies on recordkeeping and documentation.