Get Tn Bcbs 17ped153727 2017-2025

Filling out the TN BCBS 17PED153727 form is an essential step for users seeking a skilled nursing facility request. This guide provides clear and supportive instructions to help users complete the form efficiently and accurately.

Follow the steps to successfully complete the form.

1. Click 'Get Form' button to access the TN BCBS 17PED153727 document and open it for editing.
2. Begin by entering the member information. Fill in the member’s name, date of birth, identification number, reference number, and phone number accurately.
3. Indicate whether the member is enrolled in the CHOICES program or the ECF CHOICES program by checking the appropriate box.
4. Answer the questions regarding mental illness and intellectual and developmental disabilities (IDD) by marking 'Yes' or 'No' for each query.
5. If applicable, list any disabilities or mental illnesses the member has, and indicate whether Medicaid preadmission Screen and Resident Review (PASRR) services were requested.
6. Fill in the skilled nursing facility information, including the expected date of admission, facility name, contact details, and provider information.
7. Provide details for the prescribing physician and admitting physician, including their names, addresses, and contact information.
8. Complete the clinical information section by entering the diagnosis, height, weight, and current lab results.
9. Answer questions related to the patient's orientation level, therapy needs, surgery details, and pain control method.
10. Document any comorbidities, functional status prior to admission, and home environment considerations.
11. Assess the current functional status using the FIMS score and document the necessary details in the wound care and progress sections.
12. If applicable, outline any skilled needs and behavioral health organization issues.
13. Summarize discharge goals and the anticipated destination after discharge.
14. For retro requests, provide an explanation if needed.
15. Once you have filled in all sections of the form, review the information for accuracy, then complete your process by saving changes, downloading, printing, or sharing the form as necessary.

Take action now and complete the TN BCBS 17PED153727 online to ensure your request is processed smoothly.