THE COMMONWEALTH OF MASSACHUSETTS 
Executive Office of Health and Human Services 

Home-Bound Assessment Form 

Please complete each part of this form. All information is required. Incomplete 
forms will not be accepted. 

SECTION I 

Provider Name:
MassHealth Provider ID: 
Patient Name: 
MassHealth Member ID: 
Dates of Service: 

SECTION II 

Please check one or more of the following statements that indicate why the 
patient is not homebound as defined by Social Security Act - Sec. 1814(a). 
and §1835(a). [42 U.S.C. 1395f(a) and 1395n(a)]. Identify or explain the general 
reason the patient is not homebound. Select one of the common 
statements provided below, or state the reason that the patient is not homebound 
under “Other.”

Physician did not certify the patient is confined to his or her home. 
Patient is able to leave home without a considerable and taxing effort. 
Patient leaves the home for long periods, other than for medical treatment, 
religious services, or the trip is infrequent/occasional. 
Patient does not have an illness or injury that restricts his or her ability to 
leave home. 
Other 


SECTION III 

Attach copies of clinical records that indicate the patient is not homebound as 
defined by Social Security Act - Sec. 1814(a). and §1835(a). [42 U.S.C. 
1395f(a) and 1395n(a)]). Select the type of documentation that will be submitted 
as evidence to support the homebound status of the given patient. If the type of 
documentation is not listed, select “Other,” and then provide a brief 
description of the document type. 


Plan of Care (485/487)

Physician Orders

Skilled Nursing/Therapy Notes

Outcome and Assessment Information Set (OASIS)

MD Face-to-Face Certification

Other _______________________________________________________________ 

SECTION IV 

Please provide any additional information that may be relevant to the issue of 
whether this patient is homebound as defined by Social Security Act - Sec. 
1814(a). and §1835(a). [42 U.S.C. 1395f(a) and 1395n(a)]). Any additional 
information relevant to the patient’s homebound status should be included in 
this section. This section may be left blank if the supporting documentation 
provides a full description of homebound status. 

SECTION V – Provider of DME Attestation, Signature, and Date 

I certify under the pains and penalties of perjury that the information on this 
form and any attached statement that I have provided has 
been reviewed and signed by me, and is true, accurate, and complete, to the best 
of my knowledge. I also certify that I am the provider or, in 
the case of a legal entity, duly authorized to act on behalf of the provider. I 
understand that I may be subject to civil penalties or criminal 
prosecution for any falsification, omission, or concealment of any material fact 
contained herein. 

Provider’s signature (Signature and date stamps, or the signature of anyone 
other than the provider or a person legally authorized to sign 

on behalf of a legal entity, are not acceptable.): 

Printed legal name of provider: 

Printed legal name of individual signing (if the provider is a legal entity): 

Date: ________________ 

HBA (09/12) 




Instructions for Submitting the Homebound Assessment Form 

1) Send a general request e-mail to hhmedicareappealshomebound@umassmed.edu. 
This e-mail should state that you are requesting a secure connection to transmit 
a homebound assessment form. 

2) You will receive instructions from MassHealth about the secure e-mail 
connection. Please wait until you receive this information. Do not send any 
documentation directly to the above e-mail address, as they will not be secure. 
After you have received the first secure transmission e-mail from MassHealth, 
you are then set up to send all future documents via the 
secure e-mail system. 

3) Using the secure e-mail connection, submit the completed HA Form and 
supporting documentation to MassHealth. 

In addition, MassHealth has the capability of accepting the HA Form and 
supporting documentation through a secure FTP connection. If you would prefer to 
use this transmission method, please send an inquiry e-mail to 
hhmedicareappealshomebound@umassmed.edu. 

Required Timeframes for Response 

MassHealth will respond within 10 business days of receipt of the HA Form and 
supporting documentation. MassHealth will provide a response for each case, via 
the secure e-mail connection. 

Please note: Your agency may still be required to submit a demand bill to 
Medicare upon MassHealth review. To ensure that timely Medicare filing 
requirements are adhered to, please consider the above 10 business-day time 
limit into your agency’s ability to file a claim to Medicare. MassHealth will 
not expedite any reviews due to timely filing concerns.