CMS-10280 Home Health Change of Care Notice (HHCCN)

Patient Name:	Home Health Agency:
Patient Identification Number:	Address:
	Phone Number:

Home Health Change of Care Notice (HHCCN)

Your home health care is changing

Starting on , your home health agency will change the items/services listed below.

What items/services are changing?	Reason for change

Why are you getting this notice?

• Your doctor/provider changed (or didn’t renew) the order for your home care. The home health agency must follow doctor/provider orders to give you care. If you don’t agree with this

change, discuss it with your home health agency or the doctor/provider who orders your home care.

• Your home health agency decided to stop giving you the items/services for the reasons listed above. If you think you still need home care, you can look for care from a different

home health agency if you have a valid order. For help finding a different home health agency, contact the doctor/provider who ordered your home care. If you get care from a different home health agency, you can ask it to bill Medicare.

Get help or more information

If you have questions about these changes, contact your home health agency and/or the doctor/provider who orders your home care. You can’t appeal to Medicare about payment for the items/services listed above unless you get the items/services and a Medicare claim is filed.

Optional details:

Sign below to show you understand this notice

Return this signed notice to your home health agency in person or by mail to the address above.

• Check here if you’re signing as an Authorized Representative and make sure your name is legible or print your name, if not legible.

Signature of patient or Authorized Representative

Date

You have the right to get your information in an accessible format, like large print, Braille, or audio. You also have the right to file a complaint if you feel you’ve been discriminated against. Visit Medicare.gov/about-us/accessibility-nondiscrimination-notice, or call 1-800-MEDICARE (1-800-633-4227) for more information. TTY users can call 1-877-486-2048.

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1196. This information collection is for the Home Health Agencies to notify original Medicare beneficiaries receiving home health care benefits of plan of care changes. The time required to complete this information collection is estimated to average less than 4 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is mandatory under 42 U.S.C. 1395(bbb) and 42 CFR 484.10(c). If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Form CMS-10280 (Exp. XX/XX/XXXX)

OMB Approval No. 0938-1196