Get Inpatient Form

Completing the Inpatient Form online is a straightforward process designed to facilitate the admission of patients in various care settings. This guide will provide a step-by-step approach to ensure that you fill out the form accurately and efficiently.

Follow the steps to complete the Inpatient Form with ease.

1. Click the ‘Get Form’ button to obtain the Inpatient Form. This will allow you to open the document in your preferred editing platform.
2. In the member section, provide your Member Plan ID, last name, first name, phone number, today’s date, and date of birth. Ensure all information is current and accurate.
3. In the requesting provider section, fill in the provider ID, last name, first name, specialty, phone number, fax number, and the RP contact name if applicable.
4. If you are not entering a treating provider, you can check the appropriate box to have the plan assign one. If you do have a treating provider, fill out their information including provider ID, specialty, address, phone number, type (PCP, specialist), and fax number.
5. In the facility section, you again have the option to check a box to skip this if you want the plan to assign the facility. If entering details, provide the facility ID, name, address, phone number, and planned date of service including the month, day, and year.
6. In the service requested section, indicate the planned admission date and the requested length of stay in days. Input the primary ICD-9 code along with a brief description, followed by the primary CPT-4 code and its description, and any revenue code and description that apply.
7. Include a pertinent clinical summary if necessary, mentioning any supporting clinical records that should be attached. Finally, review the entire form for completeness.
8. After completing the form, you can choose to save your changes, download a copy for your records, print the document, or share it as necessary.

Make sure to complete your documents online for a smoother submission process.