SNF/Acute Rehab/LTAC – Initial Request ONLY Member InformationMember ID(Required) Member DOB(Required) MM slash DD slash YYYY Member Name(Required) First Last Error Field Provider InformationAgency NPI(Required) 10 DigitsRequesting Facility/Provider Name(Required) Error Field Contact Name(Required) First Last Contact Phone #(Required)Contact Fax #(Required)Email Address(Required) In order to receive confirmation of receipt request Name of Ordering Physician(Required) First Last Date of Admission (If Known) MM slash DD slash YYYY Level of Care(Required)Level of Care *SNF SkilledSNF CustodialAcute RehabLTACAccepting Facility (If Known and Different From Requesting Facility) Accepting Facility NPI (If Known) Clinical InformationDiagnosis(Required)ICD 10 DiagnosisCode Purpose of Referral(Required) 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.Accepted file types: pdf, doc, docx, Max. file size: 23 MB.Additional Comments Agreement(Required) Authorization is not a guarantee of paymentCAPTCHA