Skilled Nursing Facility, Acute Inpatient Rehabilitation ... Skilled Nursing Facility, Acute Inpatient Rehabilitation Facility Fax Assessment Form Subject: Skilled Nursing Facility, Acute Inpatient ...

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Please verify eligibility and benefits prior to request. SNF/Rehab benefits Verified No Yes. Yes, number of days available____. All therapy notes are within 24 to 48 hours of admission date or last covered date (only choose one answer) Yes No SNF member is receiving at least 1 hour of therapy 5 days a week (only choose one answer) Yes No Acute rehab member is receiving OT or PT at least 3 hours per day, 5 days per week and able to sit for 1 hour a day(only choose one answer) Yes NoAssessment type/coverageMember name Skilled Nursing Facility, Acute Inpatient Rehabilitation Facility Fax Assessment FormFacility type: SNF Member/facility informationDate of birth Admitting facility and NPI number Member phone number Policy number Facility reviewer name Hospital Admission date Phone number Fax number Address Admission Information Admission date to SNF/IPR Admitting doctor (first/last name and NPI#) Physician address/phone number Clinical information/basics Vital signs: T P Continent IncontinentBowel:Continent IncontinentBladder:Cath/Type:Hospital admitting diagnosis and ICD-10 CM code Diet: NPO orYesType:NoTube feeding:Complications IV/PICC line: Yes NoSurgical procedure Date O2 delivery: None or Type:Sat:Yes NoVent Settings:Vent:Medical historyHeight Weight Prior level of function (home)ELOS (# of days)frequency/24H:Suction None or Freq:Respiratory tx: Yes No Freq: Mobility current functioning Trach: None or Type:Date of PT/OT notes: Pain scale: Before managementTotal assistBed mobility: Max assist Mod MinCGA SBA Mod Ind Ind Clinical information/cognition Transfers: Total assist Max assist Mod MinCGA SBA Mod Ind IndAlert and oriented X Other:Gait/distanceWF 12173 APR 16 Page 1 of 2R BP Facility and provider must participate with local Blue Cross Blue Shield plan or member may incur higher costs. Complete every field unless otherwise noted. Information must be legible. Place N/A if not applicable. Precertifications and Recertifications are not a guarantee of payment.A nonprofit corporation and independent licenseeof the Blue Cross and Blue Shield AssociationAcute Inpatient Rehabilitation Number of days requested: 7 days 10 days 14 days Facility PIN number Route Dose FrequencyAftermanagementPain location: Pain medication:Focus goal of physical therapy Disclaimer Statements and AttestationIncomplete submissions will be returned unprocessed. Please allow 24 hours for processing precertification and recertification requests. AddressComplete this form and fax it to 1-866-411-2573 for commercial contracts or send an e-fax or email to Precertification RecertificationRe-sending faxUrgent reason:For URMBT, fax form to 1-866-915-9811 or send an e-fax or e-mail to Clinical information/medicationsGait/assistiveNone or Type:Comments: Stairs: Clinical information/skin statusSize L x W x D (CM):Treatment Mobility current functioning (continued)Total assistGait/assist Max assist Mod MinCGA SBA Mod Ind IndStairs/assist Total assist Max assist Mod MinCGA SBA Mod Ind Indneeded: device:needed: List significant medication changes at reassessment that affect functioning:List IV medications (medication name, dose, frequency, start date, end date): Self-care current functioningBathing/UE: Total assist Max assist Mod MinCGA SBA Mod Ind IndBathing/LE: Total assist Max assist Mod MinCGA SBA Mod Ind IndDressing/UE: Total assist Max assist Mod MinCGA SBA Mod Ind IndDressing/LE: Total assist Max assist Mod MinCGA SBA Mod Ind IndTotal assist Max assist Mod MinCGA SBA Mod Ind IndToileting/Hygiene mgt: ADL transfers: Total assist Max assist Mod MinCGA SBA Mod Ind IndSkin status: IntactIf not intact, complete fields below and add pages as needed.Wound or incision/Location and stage:Size L x W x D (CM):Wound or incision/Location and stage:Focus occupational therapy goals: Speech therapy current statusNone Dysphagia evaluation/Modified barium swallowResult/Aspiration risk/Recommendations:Comment: Discharge plans (must be initiated upon admission)Discharge date (tentative) Home/number of levels: 1 2 3Other:HHC/companyAssisted livingFamily/support Adult foster careHome evaluation dateHome/number of steps at: Entry:Bed/bath:Equipment: Discharge barriers:Supervision needs:WF 12173 APR 16 Page 2 of 2Long-term careMedication nameDose FrequencyStart date End date Ending date1.) Current number of stairs can climb: 2.) Number of stairs in home:Discharge Home alone location OtherTreatment type and frequencyReadMe5: PopupWindow5: Follow the instructions in the box above to submit your signed and completed form.Check Box7: Check Box8: Check Box9: Check Box10: Check Box11: Check Box12: Check Box13: Check Box14: Check Box15: Check Box16: Check Box18: Check Box19: Check Box20: Check Box21: Check Box22: Check Box23: Check Box24: Check Box25: Check Box26: Check Box27: Check Box28: Check Box29: Check Box30: Check Box31: Check Box32: Check Box33: Check Box34: Check Box35: Check Box36: Check Box37: Check Box38: Check Box39: Check Box40: Check Box41: Check Box42: Check Box44: Check Box45: Check Box46: Check Box47: Check Box48: Check Box49: Check Box50: Check Box51: Check Box52: Check Box53: Check Box54: Check Box55: Check Box56: Check Box57: Check Box58: Check Box59: Check Box60: Check Box61: Check Box62: Check Box63: Check Box64: Check Box65: Check Box66: Check Box67: Check Box68: Check Box69: Check Box70: Check Box71: Check Box72: Check Box73: Check Box74: Check Box75: Check Box76: Check Box77: Check Box78: Check Box79: Check Box80: Check Box81: Check Box82: Check Box83: Check Box84: Check Box85: Check Box86: Check Box87: Check Box88: Check Box89: Check Box90: Check Box91: Check Box92: Check Box93: Check Box94: Check Box95: Check Box96: Check Box97: Check Box98: Check Box99: Check Box99a: Check Box100: Check Box101: Check Box102: Check Box103: Check Box104: Check Box105: Check Box106: Check Box108: Check Box109: Check Box days: Check Box107: Check Box104a: Text6: Text7: Text9: Text10: Text11: Text12: Text14: Text15: Text16: Text17: Text13: Text13a: Text18: Text19: Text21: Text22: Text23: Text24: Text25: Text26: Text27: Text28: Text39: Text29a: Text29b: Text29c: Text29d: Text29aa: Text30: Text31: Text32: Text33: Text34: Text34a: Text35: Text40: Text41: Text36: Text36a: Text36ab: Text37: Text37a: Text37b: Text38: Text38ab: Text42: Text43: Text43a: Text44: Text45: Text46: Text46a: Text46ab: Text46start: Text46end: Text46ending: Text47: Text48: Text49: Text50: Text51: Text52: Text53: Text54: Text55: Text56: Text56a: Text57: Text58: Text59: Text60: Text61: Text62: Check Box4: Check Box5: Check Box3: Check Box3a: Check Box3aa: Check Box3aaa: Text1a: Text29: Text38a: Text38aaaaaa: Check Box2: Text1: AGE:


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