Skilled Nursing Facility,
Acute Inpatient
Rehabilitation Facility
Fax Assessment Form
A nonprofit corporation and independent licensee
of the Blue Cross and Blue Shield Association
Re-sending fax
Precertification
Recertification
Urgent reason:
Complete this form and fax it to 1-866-411-2573 for commercial contracts or
send an e-fax or email to [email protected].
For URMBT, fax form to 1-866-915-9811 or send an e-fax or e-mail to
[email protected]
Facility and provider must participate with local Blue Cross Blue Shield plan or member may incur higher costs. Complete every
field unless otherwise noted. Information must be legible. Place N/A if not applicable. Precertifications and Recertifications are not
guarantee
a
of payment.
Incomplete submissions will be returned unprocessed.
Disclaimer Statements and Attestation
• Please allow 24 hours for processing precertification and recertification requests.
• Please verify eligibility and benefits prior to request. SNF/Rehab benefits Verified
No
Yes. Yes, number of days available____.
Yes
No
• All therapy notes are within 24 to 48 hours of admission date or last covered date (only choose one answer)
• SNF member is receiving at least 1 hour of therapy 5 days a week (only choose one answer)
Yes
No
• Acute rehab member is receiving OT or PT at least 3 hours per day, 5 days per week and able to sit for 1 hour a day
(only choose one answer)
Yes
No
When Completed
6LJQDQGGDWHKHUH
Assessment type/coverage
Facility type:
SNF
Acute Inpatient Rehabilitation Number of days requested:
7 days
10 days
ELOS (# of days)
Member/facility information
Member name
Address
Date of birth
Policy number
Hospital
Member phone number
Facility PIN number
Admitting facility and NPI number
Fax number
Phone number
Admission date
Facility reviewer name
Address
Admission Information
Admission date to SNF/IPR
Clinical information/basics
Admitting doctor (first/last name and NPI#)
Vital signs: T
Physician address/phone number
Hospital admitting diagnosis and ICD-10 CM code
Continent
BP
Incontinent
Bladder:
Continent
Incontinent
NPO
Yes
Type:
No
Cath/Type:
Complications
Surgical procedure
Date
Yes
No
O2 delivery:
None or
Type:
Vent:
Prior level of function (home)
Respiratory tx:
Yes
Sat:
Freq:
No
None or
Freq:
Type:
Pain location:
Pain medication:
Mod
Min
Bed mobility:
Total assist
Max assist
CGA
SBA
Mod Ind
Ind
Transfers:
Total assist
Max assist
Mod
Min
CGA
SBA
Mod Ind
Ind
WF 12173 APR 16 Page 1 of 2
No
None or
Trach:
Focus goal of physical therapy
Gait/distance
Yes
Vent Settings:
Suction
frequency/24H:
Mobility current functioning
Date of PT/OT notes:
or
IV/PICC line:
Medical history
Weight
P
R
Bowel:
Diet:
Tube feeding:
Height
14 days
Route
Frequency
Dose
Pain scale:
Before
management
After
management
Clinical information/cognition
Alert and oriented X
Other:
Mobility current functioning (continued)
Gait/assist
needed:
Total assist
CGA
SBA
Gait/assistive
device:
None or
Type:
Stairs:
Max assist
Mod
Mod Ind
Clinical information/medications
Min
Ind
List significant medication changes at reassessment
that affect functioning:
List IV medications (medication name, dose, frequency,
start date, end date):
1.) Current number of stairs can climb:
2.) Number of stairs in home:
Stairs/assist
needed:
Total assist
Max assist
Mod
Min
CGA
SBA
Mod Ind
Ind
Medication name
Comments:
Dose
Frequency
Start date
End date
Ending date
Clinical information/skin status
Self-care current functioning
Focus occupational therapy goals:
Skin status:
Intact
If not intact, complete fields below and add pages as needed.
Wound or incision/Location and stage:
Bathing/UE:
Bathing/LE:
Dressing/UE:
Dressing/LE:
Toileting/
Hygiene mgt:
ADL
transfers:
Total assist
Max assist
Mod
Min
CGA
SBA
Mod Ind
Ind
Total assist
Max assist
Mod
Size L x W x D (CM):
CGA
SBA
Mod Ind
Min
Ind
Total assist
Mod Ind
Min
Ind
Treatment
CGA
Max assist
SBA
Total assist
Max assist
CGA
SBA
Mod
Mod Ind
Min
Ind
Total assist
Max assist
Mod
Min
Mod
CGA
SBA
Mod Ind
Ind
Total assist
Max assist
CGA
SBA
Mod
Mod Ind
Ind
Wound or incision/Location and stage:
Min
Size L x W x D (CM):
Speech therapy current status
None
Dysphagia evaluation/Modified barium swallow
Treatment type and frequency
Result/Aspiration risk/Recommendations:
Comment:
Discharge plans (must be initiated upon admission)
Home evaluation date
Discharge date (tentative)
Home/number of levels:
1
2
Other:
Discharge
location
Home alone
HHC/company
Family/support
Assisted living
Long-term care
Adult foster care
Equipment:
Supervision needs:
WF 12173 APR 16 Page 2 of 2
Other
Home/number of steps at:
Entry:
Bed/bath:
Discharge barriers:
3