Your home health care is going to change.
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your home health agency will change the following items and/or services for the reasons listed below.
Read the information next to the checked box below. Your home health agency is giving you this information because(Required)
If you have questions about these changes, you can contact your home health agency and/or the doctor who orders your home care. You cannot appeal to Medicare about payment for the items/services listed above unless you both receive them and a Medicare claim is filed.
Additional Information: Please sign and date below to show that you received and understand this notice. Return this signed notice to your home health agency in person or by mailing it to them at the address listed at the top of this notice.
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*If a representative signs for the beneficiary, write “(rep)” or “(representative)” next to the signature. If the representative’s signature is not clearly legible, the representative’s name must be printed.
CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call: 1-800-MEDICARE or email: