Skilled Nursing Facility Admission

Prior Authorization Form

For Prior Authorization fax completed form to: (952) 853-8706

Or call: (952) 883-6333 or 1 (888) 467-0774

Member and facility information

Member Name:

Facility Name: Address:

HealthPartners ID #: Tax ID #:

DOB: Facility contact name for updates:

Medicare Covered Stay: Yes No

Days available on admission: /100

Facility contact phone #:

Confidential Voicemail YES or NO

Form completed by: Phone #:

Facility fax #:

Attending MD (first & last name):____________________________________________________________

Phone: __________________________________ Fax:__________________________

SNF Admit Date: ________________ Admit Time: _______ AM PM

Admit From: Home Hospital NH Facility Admitted From: _______________________________

Diagnosis Code: ___________________________________________________________________________

Reason for Admission: ______________________________________________________________________

Treatment Plan:____________________________________________Frequency:______________________

Therapy Plan: ______________________________________________Frequency:______________________

Anticipated Length of treatment: _____________________________________________________________ Discharge Date: ___________________________ Discharge To: Home Hospital Expired NH Comments: _______________________________________________________________________________

Attach therapy eval and notes, Admission H&P, etc. with this form