•
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 No
Assessment type/coverage
Member name
Skilled Nursing Facility,
Acute Inpatient Rehabilitation Facility
Fax Assessment Form
Facility type: SNF
M
ember/facility information
Date 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 Incontinent
Bowel:
Continent Incontinent
Bladder:
Cath/T
ype:
Hospital admitting diagnosis and ICD-10 CM code
Diet:
NPO or
Y
es
T
ype:
No
T
ube feeding:
Complications
IV/PICC line: Y
es No
Surgical procedure Date
O2 delivery:
None or Type:
Sat:
Yes No
Vent Settings:
V
ent:
Medical history
Height
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 s
cale
:
Before
management
Total assist
Bed mobility:
Max assist Mod
Min
CGA SBA
Mod Ind Ind
Clinical information/cognition
Transfers:
Total assist
Max assist Mod
Min
CGA SBA
Mod Ind Ind
Alert and oriented X
Other:
Gait/distance
WF 12173 JUN 18 Page 1 of 2
R BP
A nonprofit corporation and independent licensee
of the Blue Cross and Blue Shield Association
Acute Inpatient Rehabilitation
Number of days requested:
7 days 10 days 14 days
Facility PIN number
Route
Dose
Frequency
After
management
Pain location:
Pain medication:
Focus goal of physical therapy
Disclaimer Statements and Attestation
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 guarantee of payment.
Incomplete or illegible submissions will be returned unprocessed.
• Please allow 24
-48 hours for processing precertification and recertification requests.
Address
Re-sending fax
Precertification
Recertification
Complete this form and fax to: 1-866-411-2573
UAW Retiree Contracts fax to: 1-866-915-9811
