Get Qualchoice Fax Assessment Form 2015-2025

The QualChoice Fax Assessment Form is used to provide essential clinical information necessary for determining the need for admissions or continued stays in a skilled nursing or acute rehabilitation facility. This guide will walk you through the steps to effectively complete the form online.

Follow the steps to fill out the form online:

1. Click ‘Get Form’ button to access the QualChoice Fax Assessment Form online and have it ready for entry.
2. Begin with the disclaimer statements and attestation section. Ensure you read the statements carefully, as you will need to attest to these by providing your signature and other required details.
3. Proceed to Section I, where you will select the assessment type: Skilled Nursing Facility (SNF) or Acute Rehabilitation. Enter the number of days requested for your coverage.
4. In Section II, provide the member and facility information. Fill in the member’s name, date of birth, address, and QualChoice policy number. Additionally, include details about the admitting hospital and facility.
5. Move to Section III. In this section, input the admission information such as admission date, the name of the admitting doctor, DX reason for facility admission, and any relevant medical history.
6. Continue to Section IV, where you will input clinical information, including vital signs, bladder and bowel status, medications, mobility function, speech therapy status, and any planned discharge information.
7. Finally, review Section V for the authorized signature. Fill in the name and credentials of the person completing the form and provide your signature. Ensure the date signed is accurate.
8. Double-check your entries for accuracy. Once complete, save your changes. You may then download, print, or share the form as necessary.

Complete your QualChoice Fax Assessment Form online today for timely processing.