Shift Care Fax Information
To: Jefferson Health Plans dba Health Partners plans Shift Care Fax # (267) 515-6667	Requesting/ordering Provider Name: Click or tap here to enter text.
NPI #: Click or tap here to enter text.
Contact Name: Click or tap here to enter text.	Phone #: Click or tap here to enter text.
Date: Click or tap to enter a date.	Fax #: Click or tap here to enter text.

Provider – Please Complete Area Below
Member Name: Click or tap here to enter text.	Member ID #: Click or tap here to enter text.	Member’s DOB: Click or tap to enter a date.
Level of care requested (Skilled Nursing or Home Health Aide): Click or tap here to enter text. What days are the service being requested for? Choose an item. How many hours of service are requested? Click or tap here to enter text. Why the number of hours requested is necessary? Click or tap here to enter text. What are the skilled health care needs? (G-tube feeds, vent care, TPN, etc) Click or tap here to enter text. What activities of daily living are hands on/ help needed for? (Bathing, dressing, toileting, ambulation, eating, or grooming)Click or tap here to enter text. Shift care/ Medical Day Care (MDC): Click or tap to enter a date.
Duration of Service (up to 6 months): Click or tap here to enter text.
Agency Name: Click or tap here to enter text.	Agency Contact # Click or tap here to enter text.
Agency NPI #: Click or tap here to enter text.	Agency Fax # Click or tap here to enter text.
ICD 10/Diagnosis: Click or tap here to enter text.	☐ New ☐ Ongoing ☐ Change (Increase/Decrease/Level of Care)

Attached with Request
☐ Letter of Medical Necessity (LOMN)	☐ Recent Office Visit Notes (within the last 6 months)
☐ Head of Household (HOH) Work Verification Letter (letter should list days and hours worked).	☐ HOH Letter from their treating MD if disabled and not working. (letter must indicate HOH limitations and duration of limitations)
☐ School Schedule (if school aged)	☐ School Letter giving permission for services in school, if applicable
☐Autism Diagnostic Report	☐ Individualized Educational Plan (IEP)
☐ Recent signed Plan of Care (within 6 months)	☐ Nursing Notes
☐Home Health Aide Logs