Home-Based Hospital Care Waiver Extension Request Form
Submit your request to extend a home-based hospital care waiver. Please provide accurate and complete information to ensure timely processing. All information collected in this form is for the sole purpose of reviewing your waiver extension request.
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Contact Email
*
example@example.com
Patient Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Current Waiver Reference Number
*
Current Waiver Expiration Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Extension Request
*
Requested Extension Period (Start and End Dates)
*
Current Care/Support Status
*
Please Select
Receiving continuous home-based care
Intermittent care/support at home
Care/support temporarily paused
Other
Provider Name and Confirmation
*
Submit Extension Request
Should be Empty: