First Name, MI, Last Name Currently Inpatient: Yes No Home Mailing Address: Home Phone Number : Date of Birth (MUST be 3 or older) Medicare # (if applicable) Check here if applicant/program participant.
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How to fill out the WV WV-TBI Medical Necessity Evaluation Request Form online
Completing the WV WV-TBI Medical Necessity Evaluation Request Form online is an important step in seeking necessary support for individuals with traumatic brain injuries. This guide will assist you in accurately filling out each section of the form to ensure a smooth submission process.
Follow the steps to complete the form effectively.
- Press the ‘Get Form’ button to access the WV WV-TBI Medical Necessity Evaluation Request Form and open it in your preferred editor.
- Begin by providing the applicant's first name, middle initial, and last name in the designated fields.
- Indicate whether the applicant is currently an inpatient by selecting 'Yes' or 'No'. If 'Yes', please specify the name and address of the facility.
- Fill in the home mailing address and home phone number, along with the date of birth (confirming that the applicant is at least 3 years old). If applicable, include the Medicare number.
- Check the box if the applicant or program participant is acting as their own representative.
- Provide demographic information, including the Social Security number and county of residence.
- Select the applicant's gender and fill in any additional contact information, such as email and Medicaid number, if applicable.
- Complete the legal representative information section, including the relationship to the applicant and contact details.
- Review the signature section and ensure the applicant or legal representative signs and dates the form, certifying that the information is accurate.
- If this is a reevaluation, fill in the case management agency information, including the agency name, the case manager’s name, and their contact details.
- Provide the referring physician/practitioner information, including their name, phone number, fax number, and mailing address.
- List all diagnoses, including the type of TBI, along with the relevant ICD code(s) in the specified area.
- Check any functional deficits where assistance is needed, as applicable.
- The physician or practitioner must attest to the individual's condition by signing and dating the form.
- After completing the form, save changes, and then you can download, print, or share the form as needed.
Complete the WV WV-TBI Medical Necessity Evaluation Request Form online to ensure timely assistance for individuals in need.
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