SNF/Acute Rehab/LTAC – Initial Request ONLY

  • Member Information

  • Enter Member Id and Date of Birth and click Submit below to validate the member and fetch Member Details.
  • MM slash DD slash YYYY
  • Provider Information

  • Add a new row
    In order to receive confirmation of receipt request
  • MM slash DD slash YYYY
  • Level of Care *
  • Clinical Information

  • DiagnosisICD 10 Diagnosis Code 
    Add a new row
    Example ICD 10 Diag Code: Z87.890
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    Accepted file types: pdf, doc, docx, Max. file size: 23 MB.