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*

Did you receive an email to update fax?

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:

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?:

Send me a copy of my responses

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