UNIVERSAL HEALTH PLAN/ HOME HEALTH AUTHORIZATION FORM 
S.OC. Date: ___/___/___ Initial: � Reauthorization:___/___/___
Agency D/C Date:___/___/___: Anticipated � Actual � MD Agrees: Y/N Patient Agrees: Y/N

 Patient Information
Name:_________________________________ 
S.O.C. Address:_________________________
Telephone #:____________________________
DOB:___/___/___
Homebound: Y/N Why?___________________
Diagnosis:______________________________
Surgery: N/A___________________________
Patient Prognosis:
Poor / Guarded / Fair / Good / Very Good / 
Excellent / <6 months to live / Terminal.

MD Information 
Ordering MD:___________________________ MD Phone#:____________________________ PCP:__________________________________ Date of Next MD Visit:___/___/___ 
Health Plan Information 
Health Plan Name:_______________________ Insurance #:____________________________ Health Plan CM:________________________ Initial Auth#:___________________________ Telephone #:____________Fax #:___________ 
Agency Information 
Agency Name:______________________________ Provider Number:____________________________ Contact:____________________________________ Telephone #:______________Fax#:______________ 
DME/Supplies/IV/Lab 
Vendor Name:_______________________________ Community Resources_______________________ 
Caregiver Information 
Name:_____________________________ Relationship:________________________________ Type of Assistance:___________________________ Teachable/Not Teachable:______________________ Primary Phone#:_____________________________ 
Maternity Care N/A � 
Delivery Date___/___/___Time Of Delivery__:__ Discharge Date___/___/___Time of Discharge__:__ 
Current Functional Status
 Cognitive Dress Lower Extremities Bathing Toileting Ambulation 
�Alert/Oriented � Impaired � Disoriented 	� Independent � Requires assist � Unable 	� Independent � Requires assist � Unable 	� Independent � Requires assist � Unable 	� Independent � Requires assist � Unable	

 Service Request 	From 	To 	# Of Visits 	Frequency 	Auth # Visits 	Health Plan Auth #	
 RN							
 HHA/Hrs&Visits							
 PT							
 OT							
 ST 							
MSW							
 Other 							

Communication 
Comments:____ ___________________________________________________________ 
Name:______________________________Title:_______________Date: ___/___/___ 
Developed by Health Plan/Home Health Partnership of Massachusetts.  © Do not reproduce without permission of the Partnership Mar 1,2006. 
Page 2 Patient Name: Agency: Auth # 
SKILLED NURSING D/C Date:___/___/___ Anticipated � Actual � 

Clinical summary: 
Reason for Home Health Aide Services: 
Wound Care N/A� 	Wound 1 	Wound 2 	Wound 3 	
Location 				
Appearance 				
Measurement 				
Drainage 				
TX and Frequency 				

Medications: Compliant:  Y/N Teachable Patient: Y/N Med List Attached: NA/Y Goals/Plan for this Authorization Period: 
Barriers to Achieve Goals/Plan: 
Interventions : 
Signature: __________________________Title:______Department:_____________Date:___/___/___ 
OTHER SKILLED DISCIPLINES D/C Date: ___/___/___ Anticipated � Actual � 
Please complete a separate pg. 2 when more than one skilled discipline providing care 
PT OT ST MSW Other___________________ Reason for Home Health Aide Services: 
Clinical summary? ______________________________ 
Goals/Plan for this authorization period: 
Barriers to achieve goals/plan: 
Interventions : 
Signature: __________________________Title:______Department:_____________ Date:___/___/___ 
Developed by Health Plan/Home Health Partnership of Massachusetts. © Do not reproduce without permission of the Partnership Mar.1, 2006.