Inpatient Rehab/SNF and Emergent Admissions Form

Instructions: Complete form and fax to the number above. We follow InterQual criteria for review.

HIPAA regulations prohibit sending more clinical information than is needed for pre-cert. Do not submit the entire medical record. Only submit the information required on this form or the requested attachments. Please include H&P, pertinent consults, and last MD progress note available with all requests.

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* are required fields

*Member name: *HAP ID#: *Today’s date: *Discharging facility (hospital): *Hospital admission date: *Request admission to (facility): *Facility NPI: *Facility phone: *Date of transfer: *Person completing form: *Phone: *Fax:

*Requested Service: Skilled nursing placement Sub-acute Acute rehab Long-term acute care (LTAC) Emergent inpatient admissions

Note: Prior authorization is not required for long-term basic care placement at nursing center. LTAC is a hospital specializing in treating patients requiring extended hospitalization. For a list of contracted LTACs, visit hap.org; select Find a doctor; facilities/pharmacies; then narrow search by specialty and select long term care hospital.

CURRENT CLINICAL STATUS

*Admission diagnosis(es): *Recent surgical procedure(s) (include dates): *Additional diagnoses: *Pain scale: (none) 0-10 (severe) *Location: *IV pain medication (frequency & dose) *Cognitive status: Able to follow Unable to follow

*Step directions (check one) 1 2

*Physical functional level prior to admission: *Prior to admission, member lived: Alone With family/other support

*IN: Own Residence Assisted Living With family/other support Discharge plan after Skilled/IPR/LTAC placement: (Must complete discharge plan or anticipated discharge plan)

SKILLED SERVICES REQUIRED

Please check, fill in, circle all applicable items

PEG tube feedings: (Formula, rate and # of hours infusion) IV antibiotics/TPN: (Dose, frequency, type of line, duration) Stage III or IV wound/stasis wound/open surgical wound

(If > 1 wound include wound consult and current wound note)

Site:

Centimeter size:

length: width: depth: Stage/surgical: Treatment and frequency: Ventilator care: (Settings) Include last 2-3 respiratory care notes.

1) Ventilator care: include 3 days respiratory notes:

a) Weaning trials:

Frequency: VT: 02: PEEP: CPAP trials:

b) Trach care:

Frequency of suction: 02 requirements (%): Devices: Mask Shield Collar

Therapies

Please fax therapy evaluations and current therapy notes (done within 24 hours for IPR request; done within 48 hours for Skilled: Physical Therapy, Occupational Therapy and Speech Therapy)

*Check the number of hours of daily therapy the patient can tolerate today: 3 Hours 2 Hours 1 Hour Other:

HAP will provide verbal authorization for transfer of the member. Admitting facility must notify HAP Admissions within 24 hours of the member’s arrival. Call (313) 664-8833 (option 1) or (800) 288-5959. The facility will receive the HAP auth number upon arrival.

Upon clicking the Submit button, the form contents will be submitted to HAP.

Specified skilled service information:

For all supporting specified skilled service information, please attach any related files, note specific to the request above, list the name of the patient and their HAP ID in the body of the email, and send them to IPRS@hap.org.

Resources