* Required fields

1. Request type

To change a role or add on a new role, you must complete all training requirements specific to the role(s), unless training was completed within the last 6 months.

New providerRole changeRoll add-on
Practice name
Street address
Street address line 2
City
State
Zip code

2. Requester information

Primary contact name
Primary contact email
Primary contact phone number

3. Person receiving access

First name
Middle initial
Last name
Home address
Home address line 2
City
State
Zip code
Phone number
Email address
Date of birth
Will you be seeing members?
YesNo

4. Roles

Each role includes read/write, read-only or no Rosalind access. These are outlined below, along with other requirements and responsibilities. 

All practices require at least 1 person assigned to the following roles: Practice Manager, Supervisor, Billing Manager, Assigner and Attester. 

Practice Manager

  • Rosalind access level: Read-only and read/write access to all tabs. Read-only access to AP invoices tab
  • Training requirement: Learning Center Training Modules, One Live Webinar
  • Role responsibilities: Only role capable of requesting and assigning roles to subordinates

Supervisor

  • Rosalind access level: Read-only and read/write access to all tabs. Read-only access to AP invoices tab
  • Training requirement: Learning Center Training Modules, One Live Webinar

Billing Manager

  • Rosalind access level: Only role with read/write access to AP invoices tab. Read-only access to all other tabs.
  • Training Requirement: Learning Center Training Modules

Attester

  • Rosalind access level: Read/write access to the attestation page in Rosalind to validate OIG/SAM on behalf of all practice staff.
  • Training requirement: Learning Center Training Modules, One Live Supervisory Webinar

Trainer

  • Rosalind access level: Only role with access to the Rosalind Training Branch. Read-only and read/write access to all tabs excluding the AP invoices tab.
  • Training requirement: Live Trainer Training, Knowledge check

Program Coordinator

  • Rosalind access level: Supportive role that has read-only access to all tabs.
  • Training requirement: Learning Center Training Modules

Admin

  • Rosalind access level: None
  • Training requirement: None
  • Provided Humana email to receive communications

Assigner

  • Rosalind access level: None
  • Training requirement: None
  • Role responsibilities: Receives LTIH and Transitions daily unassigned rosters and making new member requests
  • Provided Humana email address to receive communications

 

Please indicate which of the above roles you are assigning to this person. More than 1 box may be checked.
Practice ManagerSupervisorBilling ManagerAttesterTrainerProgram CoordinatorAdminAssigner

5. Approval

Owner/DON
Date

Download the Owner Approval Form

6. Attachments

Exhibit A Attestation FormAccepted file types include .doc, .docx and .pdf with a maximum size of 5 MB.
Owner Approval FormAccepted file types include .doc, .docx and .pdf with a maximum size of 5 MB.

7. Submittal

Submit my form to

I certify that all of the representations made above are accurate and truthful. I represent that in working with Humana At Home Care Management Network, my company, employees, subcontractors and I agree to abide by the Code of Ethics of our parent profession(s). I affirm that I agree to work in a collaborative team with the other professionals and Humana At Home staff. Applicant has been vetted for any issues that could hinder this potential practice personnel’s working relationship with Humana including any pending investigations, suspensions, warnings, court hearings, open tickets, disciplines on licenses, registrations and or certifications.