Acute, SNF, LTAC, IRF Authorization Request Patient’s Current Location (If Facility, name of Facility is Needed): ER: Acute: LTAC/REHAB: Office Home Other: Request for: SNF LTAC/Rehab Acute Inpt Today’s Date: / / Patient’s Name: DOB / / Member ID: Patient PCP: NPI: Requestor Name: Requestor Phone: FAX: Expected Admit Date: / / Ordering Physician: Ordering Physician NPI: Facility: Facility NPI: Treating Physician: Treating Physician NPI: ICD-10 CM Diagnosis Description ICD-10 CM Code Describe any special circumstances which should be considered when authorizing services: Clinical Information: **Clinical Information MUST be included with Request including evaluation and clinical notes from referring facility** This request will be treated as per the standard organization determination timeframes. If the request needs to be treated as expedited, clinical justification must be provided that applying the standard time for making a determination could seriously jeopardize the life or health of the member or the member’s ability to regain maximum function: _ _
Acute, SNF, LTAC, IRF Authorization Request Patient’s Current Location (If Facility, name of Facility is Needed): ER: Acute: LTAC/REHAB: Office Home Other: Request for: SNF LTAC/Rehab Acute Inpt Today’s Date: / / Patient’s Name: DOB / / Member ID: Patient PCP: NPI: Requestor Name: Requestor Phone: FAX: Expected Admit Date: / / Ordering Physician: Ordering Physician NPI: Facility: Facility NPI: Treating Physician: Treating Physician NPI: ICD-10 CM Diagnosis Description ICD-10 CM Code Describe any special circumstances which should be considered when authorizing services: Clinical Information: **Clinical Information MUST be included with Request including evaluation and clinical notes from referring facility** This request will be treated as per the standard organization determination timeframes. If the request needs to be treated as expedited, clinical justification must be provided that applying the standard time for making a determination could seriously jeopardize the life or health of the member or the member’s ability to regain maximum function: _ _