Texas Medicaid uses form F00028, the Home Health Plan of Care, to prior authorize home health skilled nursing and home health aide visits, therapy, supplies and DME through TMHP. A physician or allowed practitioner meets it when signing the plan of care for a client receiving home health services. The home health agency submits it, and TMHP reviews the orders and medical necessity narrative.
The home health agency fills in the client, agency, PPECC and plan of care details, and the agency RN signs. The physician or allowed practitioner provides diagnoses, orders and medical necessity, then signs the plan of care and the conflict of interest statement.
Download the current version from the source each time; forms change without notice.
Home Health Plan of Care (POC)
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Diagnoses, functional limitations, permitted activities and homebound status, prescribed medications, diet, mental status, prognosis, rehabilitation potential and safety precautions, plus a brief narrative of medical necessity, clinical condition and treatment plan, including discharge instructions. The request lists HCPCS services and the skilled nursing and aide visits requested.
Yes. The plan of care status box covers new clients, extensions and revised requests, with the original start-of-care date and, for revisions, the effective date of the change. Fields marked with an asterisk are essential; if any of them is blank, TMHP returns the request.