Get Mi Bcn Ltach Assessment Form 2013-2025

Filling out the MI BCN LTACH Assessment Form online is a crucial step in ensuring that members receive appropriate long-term acute care. This guide will provide you with step-by-step instructions to help you complete the form with confidence.

Follow the steps to effectively complete the MI BCN LTACH Assessment Form online.

1. Click the ‘Get Form’ button to access the MI BCN LTACH Assessment Form; this action will open the form in your designated editor.
2. Enter today’s date at the top of the form. Choose whether this submission is for precertification or recertification by marking the appropriate box.
3. In the MEMBER and LTACH INFORMATION section, fill in the MEMBER name and contract number. Include necessary medical documents such as hospital admission history and medication lists.
4. Provide the date of birth, current phone number, and age of the member. Indicate their living situation by marking whether they reside alone, with a spouse, or with others.
5. Describe the home environment, including any steps to enter and locations of essential facilities like the bed and bath.
6. Detail the support system by marking applicable options for family and friends, and provide a summary under comments.
7. In the acute hospital information section, specify the hospital name and admission date. Include the contact person’s name and phone number.
8. Enter the LTACH name, admission date, and relevant contact information for the LTACH reviewer, including phone and fax details.
9. Provide information on the admitting physician and include details regarding the admitting diagnosis, summarizing the acute hospital admission.
10. Document past medical history and any surgeries or procedures along with their dates.
11. If applicable, list three skilled nursing facilities (SNF) that have denied admission, including the staff name and phone number for each.
12. Complete the CLINICAL INFORMATION section with vital measures like height, weight, blood pressure, and medication details.
13. Indicate the member's pain levels and related medications if applicable.
14. In the REHABILITATION THERAPY section, fill out the details for physical, occupational, and speech therapy needs.
15. Provide tentative discharge plans, including the contact person and their phone number.
16. Use the additional comments section to provide any other relevant clinical information.
17. Once all fields are completed, you can save your changes, download, print, or share the form as needed.

Start filling out the MI BCN LTACH Assessment Form online to ensure swift and efficient processing.