Get Mpb Group Ppo Non-michigan Acute Inpatient Fax Assessment Form

This guide provides a clear and structured approach to completing the MPB Group PPO Non-Michigan Acute Inpatient Fax Assessment Form online. By following these instructions, users can ensure that their submissions are accurate and complete, ultimately facilitating the assessment process effectively.

Follow the steps to accurately complete the assessment form.

1. Press the ‘Get Form’ button to obtain the form and open it in the designated editor.
2. Begin by entering your contact information. Fill in the title, contact name, phone number, date, and fax number. Ensure all information is legible.
3. Provide patient information, including the patient's name, signature, date of birth, email address, policy number, city, address, state, and any necessary ZIP code.
4. Complete the precertification section. Indicate the type of admission (ER admit, direct admit, elective admit, etc.) and provide the phone number for the facility, the estimated length of stay, and the admission date.
5. If applicable, complete the surgical admissions section by listing the surgical procedures and CPT codes, including the surgery date.
6. Fill out the recertification section with the number of days requested, current estimated length of stay, and last covered date.
7. In the medical admissions section, document the admitting diagnosis and ICD9 codes, as well as the patient's height and weight.
8. Complete the assessment and treatment details, including vital signs like BP, heart rate, respiratory rate, and temperature.
9. Provide medical history, co-morbidities, family history, pertinent lab/imaging/test results, and current treatment plans.
10. Detail current medications with frequency, and fill out the skin status information, including wound/incision location, stage, size, and treatment.
11. Assess pain status by rating the pain, its location, and the effectiveness of the medications taken.
12. Decide whether a referral to case management is needed and provide tentative or actual discharge dates along with the living situation of the patient.
13. Finalize discharge plans by indicating assistive devices and the support network (spouse, family/friend, etc.) before completing the form.
14. Review all sections for completeness, then save your changes. You may choose to download, print, or share the form as needed.

Begin completing the MPB Group PPO Non-Michigan Acute Inpatient Fax Assessment Form online today for a seamless submission process.