Post on 25-Sep-2020
https://providers.amerigroup.com
NJPEC-1977-19 February 2020
Personal Care Assistant (CHHA) Request Form Fax the completed form and any supplemental documents to 1-888-240-4716. If you have questions about this communication, contact 1-855-661-1996. ☐ New ☐ Recertification — Submit 30 days prior to the authorization end date. ☐ Increase — Include physician’s prescription.
☐ Insurance transfer Former insurance carrier’s name — Include the former insurance carrier’s notice of eligibility with this form:
☐ Agency transfer Agency name — Include the member’s transfer letter stating the reasons for the request:
Member information
Name:
Address:
Member ID: SSN: DOB:
Gender: ☐ Male ☐ Female Phone:
The member lives ☐ Independently ☐ With caregivers ☐ Boarding home ☐ Assisted living ☐ Nursing home ☐ Group home ☐ Residential health care facility ☐ Other
If translation services are required, please specify the language:
Medicaid waiver program: ☐ GO ☐ CCW ☐ TBI ☐ CRPD ☐ AACAP Is this service included in the case manager’s plan of care? ☐ Yes ☐ No (If yes, attach approval.)
Case manager: Phone:
Diagnosis — worded and numeric five digits:
Current or requested hours — if applicable:
Member’s alternate contact:
Relationship: Home number: Cell:
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Physician information
Name:
Address:
NPI: Fax: Office:
Provider information
Agency name:
Address:
Amerigroup Community Care provider ID:
Phone: Fax:
Contact person:
Attestation
I hereby attest that the aforementioned agency has received a physician certification indicating the member’s need for personal care assistant services. I understand that Amerigroup can request a copy of this certification 30 days after services are ordered.
Print name:
Signature:
Date: