Michigan Medicaid home health agencies use this typed request to get prior authorization for home health aide visits, billed as G0156, for up to 90 days at a time. Beyond the agency's details, it records the beneficiary's diagnoses, medications, cognition, OASIS function scores and the aide tasks requested. A practitioner signs that they examined the patient and that aide services are medically necessary.
The home health agency completes items 2 to 37. Three signatures are required: the patient or parent or guardian (item 38), the physician, nurse practitioner, clinical nurse specialist or physician assistant (item 39), and the supervising RN, PT, OT or speech-language pathologist (item 40).
Download the current version from the source each time; forms change without notice.
Home Health Aide Prior Approval Request/Authorization
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
A physician, nurse practitioner, clinical nurse specialist or physician assistant signs item 39, certifying they examined the patient and found home health aide services medically necessary under the supervision of a registered nurse or other licensed professional. MDHHS returns any request missing a required signature.
Prior authorization for home health aide services is granted for no more than 90 days. If aide services remain medically necessary, the agency submits a new request marked Continuing. MDHHS advises the agency to keep a copy of the form until the approval or denial comes back.
The agency's most recent plan of care must accompany every request, and a copy of the OASIS is attached with the initial request and annually thereafter. The Home Health chapter of the Medicaid Provider Manual lists any other required documentation.