Sub-Acute Rehab (Sar) Prior Authorization Form - Priority Health Page 2

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Sub-Acute Rehab (SAR) Prior Authorization/Review Form

All Priority Health Products

Fax form to: 616 975-8848

Reset Form

**Please fax each patient request separately**

Discharge Summary:

Please send completed form, discharge summary, including medication list, and therapy

minutes log to Priority Health within 24 hours.

Member Name:

DOB:

Anticipated discharge site:

Barriers to discharge:

Comments/Nursing Notes:

Clinical Update:

Date of assessment:

Allergies:

Other family contact:

Relationship:

Phone:

Prior level of function:

Next patient care conference:

Home evaluation completed?

Yes

Scheduled date:

Caregiver training initiated?

Therapy

Nursing (check the appropriate box if yes)

Peg/J-tube

Restricted LE WB

Stage

Severe Obesity (BMI > 40)

Pressure

Vascular Wound

Ventilator

Ulcer

Hemodialysis (>2x/wk)

Basic Mobility and ADL’s

Indep

Mod Indep

SBA/Super

CGA

Min

Mod

Max

Dep

Ambulation

Device:

Distance:

W/C Mobility Assist

Sit to Stand

Bed to Chair Transfer

Chair to Bed Transfer

Toilet Transfer

<1 min

1-10 min

>10 min

Stairs:

Unable

1 step

3-5 Steps

>5 Steps

Standing Tolerance

w/device

# of Steps

Require Rail with Stairs

Yes

Assist with Stairs

Eating (use of utensils)

Grooming

UB Bath/Dress

LB Bath/Dress

Toileting

Tub Shower Transfer

Upper Ext ROM/Strength

0/5

1/5

2/5

3/5

4/5

5/5

Fine Motor

Poor

Fair

Good

Normal

Diet:

Swallowing Difficulties:

Yes



A & O

Person

Place

Time

Situation

Unable

Alot

Alittle

None

Difficulty carrying on a conversation with a familiar person in a noisy environment?

Difficulty remembering things such as steps to complete daily activities, people’s names etc?

Difficulty currently coping with unexpected daily event?

Difficulty currently getting to know new people?

Difficulty currently managing time to do most daily activities?

Difficulty explaining how to do something involving several steps to another person?

Difficulty telling someone that what they are doing is bothering you?

Difficulty reading the newspaper or magazine?

Difficulty being understood during ordinary conversation?

Difficulty describing something that has happened so that others understand?

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March 2014