Home Health Change of Care Notice (HHCCN)

Patient Name: Eleanor Brooks Home Health Agency: Riverbend Home Health Address: 220 Hatcher Lane, Columbia, TN 38401 Phone Number: 931-555-0163 Your home health care is changing Starting April 7, 2025, your home health agency will change your care. What is changing? You will get physical therapy visits less often. Right now you get 3 visits a week. After the change, you will get 1 visit a week. Why is it changing? Your therapist's notes show that you can now walk 300 feet with a cane. Your therapist also says you can do your home exercises on your own. Why did you get this notice? Your home health agency has decided to stop some of your care. If you still think you need home care, you can look for a different home health agency. You need a valid order from your doctor or provider to do this. To find a different agency, ask the doctor or provider who ordered your home care to help you. If you choose a different agency, that agency can send the bill to Medicare. Do you have questions? Call your home health agency or the doctor or provider who orders your home care. You cannot appeal to Medicare about payment for these services unless you get the services and a Medicare claim is filed. Please sign this notice to show you understand it. Sign it and return it to your home health agency in person or by mail at the address above. Signature of patient or authorized representative: ____________ Date: ____________ Your rights You can get this information in another format, such as large print, Braille, or audio. If you feel you have been treated unfairly because of who you are, you can file a complaint. Go to Medicare.gov/about-us/accessibility-nondiscrimination-notice or call 1-800-MEDICARE (1-800-633-4227). If you use a TTY, call 1-877-486-2048.

**Notice: Your Home Health Care Is Changing** **Patient:** Eleanor Brooks **Home health agency:** Riverbend Home Health **Address:** 220 Hatcher Lane, Columbia, TN 38401 **Phone:** 931-555-0163 **What is changing?** Starting April 7, 2025, you will get fewer physical therapy visits. You now get 3 visits each week. You will get 1 visit each week. **Why is this happening?** Your therapist's notes show that you are doing better. You can now walk 300 feet with a cane. You can also do your exercises at home by yourself. **Why did you get this letter?** Your home health agency has decided to cut back on your visits. If you think you still need more care, you can ask a different home health agency to help you. To do this, you need a valid order from your doctor. Your doctor or the provider who ordered your care can help you find another agency. If you switch, you can ask the new agency to bill Medicare. **Where can you get help?** If you have questions, call your home health agency or your doctor. You can only appeal to Medicare about payment for these services if you actually get the services and a Medicare claim is filed. **Please sign this letter** Your signature shows that you understand this letter. It does not mean you agree with the change. Please send the signed letter back to Riverbend Home Health. You can bring it in person or mail it to the address above. Signature of patient or representative: ____________ Date: ____________ **Other rights you have** - You can ask for this letter in a different format, such as large print, Braille, or audio. - You can file a complaint if you feel you were treated unfairly because of who you are. To learn more, go to Medicare.gov/about-us/accessibility-nondiscrimination-notice. You can also call 1-800-MEDICARE (1-800-633-4227). If you use a TTY, call 1-877-486-2048.

**Patient Name:** Eleanor Brooks **Home Health Agency:** Riverbend Home Health **Address:** 220 Hatcher Lane, Columbia, TN 38401 **Phone Number:** 931-555-0163 ## Notice: Your Home Health Care Is Changing ## What is changing? Starting **April 7, 2025**, you will get **fewer physical therapy visits**. - **Now:** 3 visits each week - **Starting April 7:** 1 visit each week ## Why is it changing? Your therapist wrote down that you are getting stronger. You can now: - Walk 300 feet (about the length of a football field) with a cane - Do your home exercises by yourself ## Why did you get this letter? Your home health agency decided to give you fewer visits for the reasons above. The law says we must tell you about this change in writing. ## What if you think you still need more visits? - You can get care from a **different** home health agency. To do this, you need an order from your doctor. - Your doctor can help you find a different agency. - If you go to a different agency, you can ask them to bill Medicare. ## Questions? Call your home health agency at **931-555-0163**. You can also talk to the doctor who ordered your home care. **Please note:** You can't ask Medicare to review payment for the visits you are no longer getting. You can only do that if you get the visits and a bill is sent to Medicare. ## Please sign this letter Signing shows that you understand this letter. It does **not** mean you agree with the change. After you sign, give this letter back to your home health agency. You can hand it to them or mail it to the address at the top of this page. Signature of patient or person signing for the patient: ____________ Date: ____________ ## Other ways to get this letter You can ask for this letter in a form that is easier for you to use, like: - Large print - Braille - Audio (a recording you can listen to) If you feel you have been treated unfairly, you have the right to file a complaint. To learn more: - Go to **Medicare.gov/about-us/accessibility-nondiscrimination-notice** - Call **1-800-MEDICARE (1-800-633-4227)** - If you use TTY (a phone service for people who are deaf or hard of hearing), call **1-877-486-2048**

**Notice: Your Home Health Care Is Changing** **Patient:** Eleanor Brooks **Home health agency:** Riverbend Home Health **Address:** 220 Hatcher Lane, Columbia, TN 38401 **Phone:** 931-555-0163 **What is changing?** Starting April 7, 2025, you will have fewer physical therapy visits. Right now, you get 3 visits each week. After April 7, you will get 1 visit each week. **Why is this changing?** Your therapist wrote notes about how you are doing. You can now walk 300 feet with a cane. You can also do your exercises at home by yourself. **Why are you getting this letter?** Riverbend Home Health has decided to cut back your care. The reasons are above. You may feel you still need more home care. If so, you can ask a different home health agency to help you. To do this, you must have an order from your doctor for home care. Your doctor or health care provider can help you find a different agency. If you use a different agency, you can ask them to bill Medicare. **Where can you get help?** If you have questions, you can call Riverbend Home Health. You can also call the doctor who ordered your home care. You cannot ask Medicare to review the payment for this care right now. You can only do that if you get the care and someone sends a bill (called a claim) to Medicare. **Please sign this letter** Sign below to show that you read this letter and understand it. Then give it back to Riverbend Home Health. You can bring it in person or mail it to the address above. Signature of patient or helper (authorized representative): ____________ Date: ____________ **Your rights** You can ask for this letter in a way that is easier for you to use. This could be large print, Braille, or audio. If you think someone treated you unfairly, you can make a complaint. To learn more, go to Medicare.gov/about-us/accessibility-nondiscrimination-notice. You can also call 1-800-MEDICARE (1-800-633-4227). If you use a TTY phone, call 1-877-486-2048.

**Notice: Your Home Health Care Is Changing** **Patient:** Eleanor Brooks **Home health agency:** Riverbend Home Health **Address:** 220 Hatcher Lane, Columbia, TN 38401 **Phone:** 931-555-0163 **What is changing?** Starting April 7, 2025, you will have fewer physical therapy visits. You now get 3 visits each week. After this date, you will get 1 visit each week. **Why is this changing?** Your therapist's notes show that you can now walk 300 feet with a cane. You can also do your exercises at home on your own. **Why am I getting this notice?** Your home health agency has decided to cut back your care for the reason above. If you think you still need more care, you can look for a different home health agency. To do this, you must have a valid order for home care. Your doctor or provider who ordered your home care can help you find another agency. If you switch, you can ask the new agency to bill Medicare. **Where can I get help?** If you have questions, contact your home health agency or the doctor or provider who ordered your care. Please know that you cannot appeal to Medicare about payment for these services unless two things happen. You must receive the services, and a Medicare claim must be filed. **What do I need to do?** Please sign and date this notice to show that you understand it. Signing does not mean you agree with the change. Then return it to your home health agency. You can bring it in person or mail it to the address above. Signature of patient or authorized representative: ____________ Date: ____________ **Your rights** You have the right to get this information in a format that works for you, such as large print, Braille, or audio. You also have the right to file a complaint if you feel you were treated unfairly because of who you are. To learn more, visit Medicare.gov/about-us/accessibility-nondiscrimination-notice or call 1-800-MEDICARE (1-800-633-4227). If you use a TTY, call 1-877-486-2048.

**Notice: Your Home Health Care Is Changing** **Patient:** Eleanor Brooks **Agency:** Riverbend Home Health **Address:** 220 Hatcher Lane, Columbia, TN 38401 **Phone:** 931-555-0163 **What is changing** Starting on April 7, 2025, your physical therapy visits will change. You now get 3 visits each week. After this date, you will get 1 visit each week. **Why it is changing** Your therapist's notes show that you can now walk 300 feet with a cane. They also show that you can do your home exercises on your own. **Why you are getting this notice** Your home health agency has decided to cut back the services listed above, for the reasons given above. **What you can do** - If you think you still need more home care, you can look for care from a different home health agency. You can do this if you have a valid order for care. - If you need help finding a different agency, contact the doctor or provider who ordered your home care. - If you get care from a different home health agency, you can ask that agency to bill Medicare. **Get help or more information** - If you have questions about these changes, contact your home health agency (Riverbend Home Health at 931-555-0163). You can also contact the doctor or provider who orders your home care. - You cannot appeal to Medicare about payment for these services unless two things happen: you get the services, and a Medicare claim is filed. **Please sign this notice** Your signature shows that you understand this notice. Sign and date it below. Then return it to Riverbend Home Health. You can bring it in person or mail it to 220 Hatcher Lane, Columbia, TN 38401. Signature of patient or authorized representative: ____________ Date: ____________ **Your rights** - You have the right to get this information in a form that works for you. This includes large print, Braille, or audio. - You have the right to file a complaint if you feel you were treated unfairly because of who you are (discrimination). - To learn more, go to Medicare.gov/about-us/accessibility-nondiscrimination-notice. You can also call 1-800-MEDICARE (1-800-633-4227). - If you use a TTY, call 1-877-486-2048.

**Patient:** Eleanor Brooks **Home health agency:** Riverbend Home Health **Address:** 220 Hatcher Lane, Columbia, TN 38401 **Phone:** 931-555-0163 # Home Health Change of Care Notice (HHCCN) ## Your home health care is changing This notice is to tell you about a change in your care. **When:** The change starts on April 7, 2025. **What is changing:** Your physical therapy visits will go from 3 visits a week to 1 visit a week. **Why:** Your therapist's notes show you are doing better. You can now walk 300 feet with a cane. You can also do your home exercises on your own. ## What can you do? Riverbend Home Health decided to cut back your visits for the reason above. If you think you still need home care, you can look for a different home health agency. You must have a valid order to do this. - To get help finding a different agency, contact the doctor or provider who ordered your home care. - If you get care from a different agency, you can ask that agency to bill Medicare. ## Questions? If you have questions about these changes, contact: - Riverbend Home Health, and/or - The doctor or provider who orders your home care. ## Appeals You can appeal to Medicare about payment for these services only if you get the services and a Medicare claim is filed. If you do not get the services and a claim is not filed, you cannot appeal. ## Please sign this notice Sign and date below to show you understand this notice. Then return the signed notice to Riverbend Home Health. You can bring it in person or send it by mail to this address: 220 Hatcher Lane, Columbia, TN 38401. Signature of patient or authorized representative: ____________ Date: ____________ ## Your rights - You have the right to get this information in a way you can use. This includes large print, Braille, or audio. - You have the right to file a complaint if you feel you were treated unfairly because of who you are (discrimination). To learn more: - Visit Medicare.gov/about-us/accessibility-nondiscrimination-notice - Call 1-800-MEDICARE (1-800-633-4227) - If you use a TTY, call 1-877-486-2048