1 CUT6133-1E (6/18)

Home Care Extension Request FormIMPORTANT1. Claims submitted for these benefits are subject to lifetime maximums and any applicable deductions, coinsurances or

provisions, as specified in the members contract. Benefits issued for requested services will be subtracted from the members lifetime benefit maximum. Benefit approval is subject to the following conditions: a) member identification number is effective at the time services are rendered, b) requested benefits are available under the members contract, c) lifetime benefits not exhausted.

2. When submitting claims for habilitative services, the modifier 96 must be included. When submitting claims for rehabilitative services, the modifier 97 must be included.

3. Please contact the appropriate provider service area to verify members eligibility and benefits for requested services.

4. Claim payment for approved services does not indicate payment for future services. All future claims will be evaluated in accordance with the aforementioned benefit approval conditions and the CareFirst and/or CareFirst BlueChoice utilization management review process.

5. If you have any questions regarding the extent of this authorization, please call 800-334-3427, ext. 4402. Calls will be returned within one business day.

Participating Providers: to initiate a request and to check the status of your request, visit CareFirst Direct at carefirst.com. Fax completed form to 410-720-5630 or 410-720-5641.

HOME CARE PROVIDER INFORMATIONHome Care Provider Provider Phone # Agency Contact Name

Home Care Provider Address Provider Fax # Start of Care (SOC) Date

Provider ID # Date of Request

Email Address

MEMBER/PATIENT INFORMATIONPatients Last Name First Name M.I. Gender Date of Birth

Address (Street, and Apt or Box #), City State Zip Code

Member Group # Member ID # w/Prefix

Next Scheduled Appointment Diagnosis Code(s) (ICD-10) Homebound

Services requested (include number of visits per day/week/month)

Skilled Nursing (SN) Medical Social Worker (MSW)

Physical Therapy (PT) Home Health Aide (HHA)

Nutritionist Occupational Therapy (OT)

Speech Therapy Private Duty Nursing (PDN) Hours per day _____________

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst MedPlus is the business name of First Care, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc. and First Care, Inc., are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc.

www.carefirst.com

2

MEMBER/PATIENT INFORMATIONActual Visit Dates During Previous Auth Period for each Discipline

Wound Present Yes No

Location ________________________________________________ *If yes; must complete

1. Measurements: ________ Length _________ Width _________ Depth

2. Measurements: ________ Length _________ Width _________ Depth

Presence of Tunneling Yes No

Drainage _________ Color _________ Odor _________ Amount

Caregiver or Member instructed in wound care Yes No

Wound Vac? Yes No

Progress Report (attach current progress notes and summary)

INTERNAL OFFICE USE ONLYAuthorization # and Date

SN __________ PT __________ OT __________ MSW __________ HHA __________

SLP __________ Other __________

(CONTINUED)

Notice of Nondiscrimination and Availability of Language Assistance Services

CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc. and all of their corporate affiliates (CareFirst) comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability or sex. CareFirst does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.

CareFirst:

Provides free aid and services to people with disabilities to communicate effectively with us, such as:Qualified sign language interpretersWritten information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:Qualified interpretersInformation written in other languages

If you need these services, please call 855-258-6518.

If you believe CareFirst has failed to provide these services, or discriminated in another way, on the basis of race, color, national origin, age, disability or sex, you can file a grievance with our CareFirst Civil Rights Coordinator by mail, fax or email. If you need help filing a grievance, our CareFirst Civil Rights Coordinator is available to help you.

To file a grievance regarding a violation of federal civil rights, please contact the Civil Rights Coordinator as indicated below. Please do not send payments, claims issues, or other documentation to this office.

Civil Rights Coordinator, Corporate Office of Civil RightsMailing Address P.O. Box 8894 Baltimore, Maryland 21224

Email Address civilrightscoordinator@carefirst.com

Telephone Number 410-528-7820 Fax Number 410-505-2011

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., The Dental Network and First Care, Inc. are independent licensees of the Blue Cross and Blue Shield Association. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. In Virginia, CareFirst MedPlus is the business name of First Care, Inc. of Maryland (used in VA by: First Care, Inc.). Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc.

REV. (12/17)

Foreign Language Assistance Attention (English): This notice contains information about your insurance coverage. It may contain key dates

and you may need to take action by certain deadlines. You have the right to get this information and assistance in

your language at no cost. Members should call the phone number on the back of their member identification card.

All others may call 855-258-6518 and wait through the dialogue until prompted to push 0. When an agent

answers, state the language you need and you will be connected to an interpreter.

(Amharic) -

855-258-6518 0

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tt a fi s fn lti t 0. Ngbt aoj kan b dhn, s d t o f a s so p m gbuf kan.

Ting Vit (Vietnamese) Ch : Thng bo ny cha thng tin v phm vi bo him ca qu v. Thng bo c th

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n khi c nhc nhn phm 0. Khi mt tng i vin tr li, hy nu r ngn ng qu v cn v qu v s c

kt ni vi mt thng dch vin.

Tagalog (Tagalog) Atensyon: Ang abisong ito ay naglalaman ng impormasyon tungkol sa nasasaklawan ng iyong

insurance. Maaari itong maglaman ng mga pinakamahalagang petsa at maaaring kailangan mong gumawa ng

aksyon ayon sa ilang deadline. May karapatan ka na makuha ang impormasyong ito at tulong sa iyong sariling

wika nang walang gastos. Dapat tawagan ng mga Miyembro ang numero ng telepono na nasa likuran ng kanilang

identification card. Ang lahat ng iba ay maaaring tumawag sa 855-258-6518 at maghintay hanggang sa dulo ng

diyalogo hanggang sa diktahan na pindutin ang 0. Kapag sumagot ang ahente, sabihin ang wika na kailangan mo

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Espaol (Spanish) Atencin: Este aviso contiene informacin sobre su cobertura de seguro. Es posible que

incluya fechas clave y que usted tenga que realizar alguna accin antes de ciertas fechas lmite. Usted tiene

derecho a obtener esta informacin y asistencia en su idioma sin ningn costo. Los asegurados deben llamar al

nmero de telfono que se encuentra al reverso de su tarjeta de identificacin. Todos los dems pueden llamar al

855-258-6518 y esperar la grabacin hasta que se les indique que deben presionar 0. Cuando un agente de seguros

responda, indique el idioma que necesita y se le comunicar con un intrprete.

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na ma 0 k dyi paain hw. ju ke ny o dyi m g juin, po wuu m m po dyi, ke ny o mu o niin

ke ni wuu mu za.

(Bengali) : 855-258-6518 0

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(Traditional Chinese)

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mkpa, nwere ike me ihe tupu fd bch njedebe. nwere ikike nweta ozi na enyemaka a nass g na

akwgh gw bla. Nd otu kwesr kp akara ekwent d naz nke kaad njirimara ha. Nd z niile nwere

ike kp 855-258-6518 wee chere bb ah ruo mgbe amanyere p 0. Mgbe onye nnchite anya zara, kwuo

ass chr, a ga-ejik g na onye kwa okwu.

Deutsch (German) Achtung: Diese Mitteilung enthlt Informationen ber Ihren Versicherungsschutz. Sie kann

wichtige Termine beinhalten, und Sie mssen gegebenenfalls innerhalb bestimmter Fristen reagieren. Sie haben

das Recht, diese Informationen und weitere Untersttzung kostenlos in Ihrer Sprache zu erhalten. Als Mitglied

verwenden Sie bitte die auf der Rckseite Ihrer Karte angegebene Telefonnummer. Alle anderen Personen rufen

bitte die Nummer 855-258-6518 an und warten auf die Aufforderung, die Taste 0 zu drcken. Geben Sie dem

Mitarbeiter die gewnschte Sprache an, damit er Sie mit einem Dolmetscher verbinden kann.

Franais (French) Attention: cet avis contient des informations sur votre couverture d'assurance. Des dates

importantes peuvent y figurer et il se peut que vous deviez entreprendre des dmarches avant certaines chances.

Vous avez le droit d'obtenir gratuitement ces informations et de l'aide dans votre langue. Les membres doivent

appeler le numro de tlphone figurant l'arrire de leur carte d'identification. Tous les autres peuvent appeler le

855-258-6518 et, aprs avoir cout le message, appuyer sur le 0 lorsqu'ils seront invits le faire. Lorsqu'un(e)

employ(e) rpondra, indiquez la langue que vous souhaitez et vous serez mis(e) en relation avec un interprte.

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(Navajo)

855-258-6518

Skilled Nursing: OffMedical Social Worker: OffPhysical Therapy: OffHome Health Aide: OffNutritionist: OffOccupational Therapy: OffSpeech Therapy: OffPrivate Duty Nursing: OffProvider Name 3: Provider Phone 3: Agency Contact 3: Provider Address 3: Provider Fax 3: SOC Date 2: Provider ID 3: Date of Request 2: Email Address 2: Patient Last Name 5: Patient FIrst Name 5: Patient MI 5: Gender 5: Date of Birth 5: Patient Address 3: Patient State 3: Patient ZIP code 3: Member Group Number 5: Member ID Number 5: Next Appointment 5: Diagnosis Code 5: Homebound 4: SN 3: MSW 3: PT 2: HHA 3: Nutritionist 3: OT 3: Speech Therapy 3: PDN 3: Hours per day: Wound present?: OffTunneling?: OffInstructed?: OffWound vac?: OffActual Visit Dates 3: Wound Location 3: Length 6: Width 6: Depth 6: Length 7: Width 5: Depth 5: Color 3: Odor 3: Amount 3: Progress Report 4: Certification No 3: Internal SN 3: Internal PT 3: Internal OT 3: Internal MSW 3: Internal HHA 3: Internal SLP 3: Internal Other 3: