Provider Attestation of Patient Diagnosis for SSBCI Eligibility

​​

​Form Requirments
To qualify for SSBCI, your patient must be a chronically ill individual who has one or more of the four active qualifying chronic conditions listed on the next page and meet all of the following:
1) is life threatening or significantly limits the overall health or function of the individual;
2) has a high risk of hospitalization or other adverse health outcomes; and
3) requires intensive care coordination.
 Eligibility for SSBCI cannot be guaranteed based solely on your patient’s conditions. All applicable eligibility requirements must be met before the benefit is provided.
​Form Instructions
Please complete this Provider Attestation of Patient Diagnosis for SSBCI Eligibility attesting that the patient meets the above criteria and documenting the qualifying conditions the patient has been diagnosed with in the past 12 months.

All fields with * are required fields and must be completed