Acute Inpatient Admission eForm Step 1 of 3 33% Member Information Enter Member Id and Date of Birth to validate Member before proceeding with the form. Member's ID#* Member's DOB* MM slash DD slash YYYY Member's Name* First Last Error Message Type of admission* ER Admission or Notification of Admission Planned future admission Admission Date* MM slash DD slash YYYY Admission Time* : Hours Minutes AM PM AM/PM Date of planned admission (if known) MM slash DD slash YYYY Procedure being performed please provide procedure code(s) to be performed during admission* Ordering MD* Ordering MD Contact* Ordering MD Contact Phone #*Ordering MD Contact Fax #*Facility InformationInpatient Facility NPI* 10 digitsInpatient facility name* Error Message Facility phone #Facility phone #*Facility fax #Facility fax #*Facility Contact Name Facility Contact Name* Attending or Admitting MD* Attending or Admitting MD fax #Email address in order to receive confirmation of request receipt* Clinical InformationPatient Medical Record number* Diagnosis (Click + or - at the right to add or remove Diagnoses)*DiagnosisICD 10 Diagnosis Code Example ICD 10 Diag Code: Z87.890Is this a maternity admission? (mom has delivered)*if mom has not delivered, please choose "no" Yes No Date of delivery* MM slash DD slash YYYY Time of delivery* : Hours Minutes AM PM AM/PM Gestational weeks at the time of delivery* Type of delivery* Vaginal delivery Primary Cesarean Section Repeat Cesarean Section Birth weight of baby (in grams)* Gender of baby* Male Female Birth outcome* Live Birth Miscarriage-nonviable <20 weeks Stillborn-non-viable 20+ weeks Attach Clinical* Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 10 MB. Upload only PDF or Word DocumentAttach Clinical Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 10 MB. Upload only PDF or Word DocumentRequest Method* Standard Expedited: By checking Expedited, you are stating that processing this request in the standard time (7 days) for making a determination could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function. Please attach documentation that supports the need for an Expedited decision. Also please note that a request with a date of service in the past cannot be considered as Expedited. Attach additional Clinical documents for Expedited request*Accepted file types: pdf, doc, docx, Max. file size: 10 MB.Attach only PDF and Word filesSignature of Physician or Licensed Provider*Signature of Physician or Licensed ProviderSignature Date* Signature Date Comments Authorization is not a guarantee of payment CAPTCHA CommentsThis field is for validation purposes and should be left unchanged.