HOME HEALTH CARE PROVIDER FAX CONFIRMATION FORM

HOME HEALTH CARE PROVIDER FAX CONFIRMATION FORM

For questions, please contact: providerdatamanagement@carelon.com

*For multiple sites please submit a request for each location.*

Carelon is committed to protecting member's Protected Health Information (PHI). To prevent disclosure of PHI to unauthorized recipients, Carelon requires confirmation of your phone and fax number. Carelon must receive this completed form prior to faxing authorization notifications. Thank you for your assistance in protecting member’s PHI.

Home Health includes SDoH and Wound Care Providers.

Health Plan*

*Please select all health plans that need the fax number confirmed*

Select

Did you receive an email to update fax?*

Select

Agency Contact Information

Name of person completing confirmation form:*

*First and Last Initial *

Contact Phone # (in case clarification is needed):*

Phone

Submitted by Email*

Branch Information

Service Provider Legal Name:*

DBA Name (if app):

Practice NPI*

TAX ID*

Location Address:*

State:*

Select or enter value

City:*

Zip Code+4*

Location Phone #:*

Location Fax #:*

*All faxes for authorization and/or requests for additional documents will be sent to this fax number. If no authorization fax is listed.*

Do you have an authorization phone or fax number?:*

Select

Authorization Contact Name/Title:

Authorization Contact Email:

Authorization Dept Phone #:

Authorization Dept Fax #:

*Secure fax numbers as member/patient information may be sent via fax.*

Send me a copy of my responses

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