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.
Member ID*
Member DOB*
MM slash DD slash YYYY
Member Name*
First Last
Error Field
Provider Information
Requesting Facility/Provider Name*
Contact Name*
First Last
Contact Phone #*
Contact Fax #*
Email Address*

In order to receive confirmation of receipt request
Name of Ordering Physician*
First Last
Date of Admission to SNF/Acute Rehab/LTAC (If Known)
MM slash DD slash YYYY
Level of Care*
Level of Care *
- SNF Skilled
- SNF Custodial
- Acute Rehab
- LTAC
Accepting Facility (If Known and Different From Requesting Facility)
Accepting Facility NPI (If Known)
Clinical Information
Diagnosis (Click + or - at the right to add additional Diagnoses)*
Diagnosis ICD 10 Diagnosis Code

Example ICD 10 Diag Code: Z87.890
Purpose of Referral*
- Rehab Therapy (PT, OT, ST)
- Skilled Nursing (IV, meds/Complex wound care, etc)
- Respiratory -Vent, Trach
- Custodial, non-skilled services
Please include any important documents of medical necessity for the requested level of care such as rehab evaluation, skilled or non-skilled needs, progress notes, discharge planning notes.
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Accepted file types: pdf, doc, docx, Max. file size: 23 MB.
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Agreement*
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Diagnosis	ICD 10 Diagnosis Code

Member Information