Long Term Care Skilled Services Form

Term, Care, Skilled, Services, Form, Sunshine, Health

Long

Brand Elements Dental Fax to 1-855-266-5275 AMBETTER BRAND ...

Manual Double Check Emergency Faith-based Prescriptions Identity Cards Questions Emergency VIsion Services Show ID Important More Community Organization Trade Associations Women’s Health Online Carry ID Dental Phone Fil…

Long Term Care Skilled Services Form - Sunshine Health

Manual. Double Check. Emergency. Faith-based. Prescriptions. Identity. Cards. Questions. VIsion. Emergency. Services. Show ID. Important. More. Community.

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PRIMARY ICON EXAMPLES

Long Term Care

Skilled Services Form

Medical

Emergency

VIsion

Dental

Behavioral

Hearing

Services

Health

Fax to 1-855-266-5275

1301 International Parkway Suite 400 Sunrise, FL 33323
1-877-211-1999 Monday through Friday 8am � 5pm

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Health

Notes

Health. Lack of clinical information may result in delayed determination. *Indicates Required Field

*Member First Name:

Provider

Identity

*MMeamnubaelr ID #: Cards

*Member Home Address:

*Member Phone Number:

Double Check

Questions

Show ID Important

MSMemALbLeIrCOHNeiEgXhAtM(iPnLEinSches):
mPhoNneew RequestPremscriEptxitoennsionBReheaqvuioeraslt
Health
Requesting Provider NPI:

Member Information

Carry ID

*Member Last Name:

Emergency

Faith-based

*Member Date of Birth:

*Service Address (if different from home):

Alternative Contact Person:

More

OCrogmanmizuanRtiiteoynlationsAhsispTorctaioadteMionesmber:

Alternative Contact Phone Number:

Member Weight (in pounds):

Requesting Provider Information

Web

Date member last seen by requesting provider:

Requesting Provider TIN:

*Requesting Provider Name:
COLOR
*Phone Number:
m Check here if this request is related to an inpatient discharge.
Raspberry

Requesting Provider Contact Name: *Fax Number:
Authorization Request
*If a Discharge, Date of Discharge: RFeavecrisleity Name:

*Primary Diagnosis Code: Additional Diagnosis Code: Number of Total Units/Visits/Days Requested:

23
*Start Date of Service: End Date of Service:

Information on services that require a prior authorization can be found at www.SunshineHealth.com. For questions please call Sunshine Health's Utilization Management Department at 1-877-211-1999 and select the prompt for home care or DME. We are open from 8 a.m. to 5 p.m. Monday through Friday.

Last Updated 3/23/2017

Long Term Care Skilled Services Form

*Member First Name:

*Member Last Name:

*Member ID Number:

*Member Date of Birth:

Home Health m Skilled Nurse m LPN m Occupational Therapy m Physical Therapy m Respiratory Therapy m Speech Therapy m Wound Care

*HCPC Code:

Description:

*Requested Services
Oxygen/Respiratory Equipment Liter Flow Per Minute: Route: m Nasal Cannula m Simple Mask m Other: Hours of Use: m Continuous m With Exertion m Hours of Sleep m Bleed into CPAP/BiPAP m Other Delivery Device: m Concentrator m Portable Cylinders m Conserving Device m Liquid Helios Portable m Other: Date of Saturation Test: Oxygen Saturation of PO2 Results: m Apnea Monitor m BiPAP m CPAP m Nebulizer m Vent
Durable Medical Equipment

Special Consideration:

Length of Need:

Additional information:

Physician Attestation and Signature
I certify that I am the treating physician identified in this form and that I have ordered the noted services.

Physician Signature:

Date:

Physician's Printed Name:

Information on services that require a prior authorization can be found at www.SunshineHealth.com. For questions please call Sunshine Health's Utilization Management Department at 1-877-211-1999 and select the prompt for home care or DME. We are open from 8 a.m. to 5 p.m. Monday through Friday.

Last Updated 3/23/2017