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: