HIQH Query / Customer Service indicatets patient under an established home health plan of care.

I, choose to transfer to My Home Nurses from Effective transfer date

I understand the initial home health agency will no longer receive Medicare Payment on my behalf and will no longer provide Medicare covered services to me after the effective date of transfer.

I request that my records be released to the receiving agency to ensure continuity of care.

Phone call to (initial home health agency) for coordination of transfer on

Beneficiary Elected Transfer / Right of Choice form sent / faxed to initial agency on