Loading
Form preview picture

Get MI BCBS Acute Inpatient Assessment Form 2013

RESET Acute Inpatient Fax Assessment Form R criteria MET InterQual O RE-SENDING FAX Recertification Complete this form and fax it to 1-866-411-2585 Or E-FAX/E-Mail to AcutePrecertification1 bcbsm.com Include hospital admission H P and PM R consultation notes as applicable A nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association Facility and provider must participate with local BCBS plan or claims may not pay. If facility/provider is not participating with member s contract network member sanction/fees may apply. Precertification does not guarantee payment. Please verify eligibility and benefits prior to request. Complete every field unless otherwise noted* Information must be legible. Place N/A if not applicable. Do not send a medical record review. Incomplete submissions will be returned unprocessed* HUMAN ORGAN TRANSPLANT Is there a potential of this member receiving a human organ transplant during this admission Yes No If Yes Has a prior authorization been completed with BCBSM s Human Organ Transplant Program HOTP If not please call the HOTP department at 1-800-242-3504. Title Contact name CONTACT INFORMATION Contact phone number Date Signature Fax number E-mail PATIENT INFORMATION Phone number Name City Address PRECERTIFICATION ER admit Direct admit Elective admit Observation Date of birth Policy number State ZIP code Estimated length of stay Admission date Facility name Facility NPI number Admitting physician Physician provider NPI number Facility phone number Physician phone number SURGICAL ADMISSIONS Surgical procedure and CPT codes Surgery date Number of days requested Current estimated length of stay Last covered date MEDICAL ADMISSIONS Admitting diagnosis and ICD9 codes Height ER/Admission assessment and treatment WF 12475 JAN 13 Page 1 of 2 BP HR Resp rate Temp Medical history/Co-morbidities/Family history Pertinent lab/Imaging/Other test results Admission orders/Current treatment plan Current medications/frequency SKIN STATUS Wound/Incision location 1 Intact Stage I II III IV Unstageable Size L x W x D cm Description Frequency Treatment Pain PAIN STATUS Rating out of 10 Location Pain meds/Frequency Effective Rating CASE MANAGEMENT BCBSM offers case management assistance for discharge planning. Would you like a referral made to our case management department Discharge plans needs to be initiated upon admission Discharge date tentative Resides Alone Assistive devices w/Spouse w/Other Support Family/friend Children HHC Home description levels bed/bath location steps to enter etc* Discharge to home Actual discharge date ALOC Rehab SNF LTC Assisted living. If facility/provider is not participating with member s contract network member sanction/fees may apply. Precertification does not guarantee payment. Please verify eligibility and benefits prior to request. Precertification does not guarantee payment. Please verify eligibility and benefits prior to request. Complete every field unless otherwise noted* Information must be legible. Place N/A if not applicable. .

How It Works

Unstageable rating
4.31Satisfied
185 votes

How to fill out and sign ltc online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

The prep of lawful documents can be costly and time-consuming. However, with our preconfigured web templates, everything gets simpler. Now, using a MI BCBS Acute Inpatient Assessment Form takes a maximum of 5 minutes. Our state browser-based samples and complete recommendations eliminate human-prone mistakes.

Comply with our simple steps to have your MI BCBS Acute Inpatient Assessment Form well prepared quickly:

  1. Select the template from the library.
  2. Enter all necessary information in the necessary fillable areas. The easy-to-use drag&drop interface allows you to add or relocate fields.
  3. Make sure everything is filled in correctly, with no typos or lacking blocks.
  4. Place your e-signature to the page.
  5. Simply click Done to confirm the adjustments.
  6. Save the document or print your PDF version.
  7. Distribute instantly to the recipient.

Take advantage of the fast search and advanced cloud editor to generate a correct MI BCBS Acute Inpatient Assessment Form. Get rid of the routine and create paperwork online!

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

Video instructions and help with filling out and completing licensee

Make the most of our instructional video guide for filling in and submitting Form with our cloud-based editor. Start now so you can relax later on.

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Norton logo picture

    Norton Secured

    The highest level of recognition among eCommerce customers.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.