Continued Snf Stay Request For Authorization Form - Healthpartners

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HealthPartners
Continued SNF Stay Request for Authorization
Fax completed form to: 952-853-8712
For questions call: 952-883-6333
Submit this form by (certified end date) as well as 2 days prior to end of therapies or discharge date
Patient and Facility Information
Member Name: ______________________
Facility Name: _________________________________
HealthPartners ID#:____________________
Facility Contact Name: __________________________
DOB: _______________________________
Facility Contact Phone: __________________________
Discharge Date (If Applicable):______________
Facility Fax: ___________________________________
Discharge Destination:
Home
Hospital
Nursing Home Other: ______________________
Physical Restrictions:
NO
YES (specify) ___________________________________
Physical Therapy: Sessions per week ____ Sessions per day ____ Minutes per session ________
Sit/Stand:
Dep
Max
Mod
Min
CGA S
I
Endurance: ____________________
Balance: ______________________
Pivot/Trfr:
Dep
Max
Mod
Min
CGA S
I
ROM: ________________________
Ambulation: Dep
Max
Mod
Min
CGA S
I
Distance: ______________________
Current Assistive Device: _______________________________ Pain: _________________________
Stairs: _______________________________________________ W/C Mob: _____________________
Comments: ___________________________________________________________________________
Occupational Therapy: Sessions per week ____ Sessions per day ____ Minutes per session ______
Grm/Hyg:
Max
Mod
Min
CGA SBA
Sup
I
Bed Mob: ______________________
UE Dsg:
Max
Mod
Min
CGA SBA
Sup
I
MMSE: ________________________
LE Dsg:
Max
Mod
Min
CGA SBA
Sup
I
IADLs: ________________________
Toileting:
Max
Mod
Min
CGA SBA
Sup
I
Current Assistive Device: _______________________________ Pain: __________________________
Comments: ___________________________________________________________________________
Speech Therapy:
Sessions per week ____ Sessions per day ____ Minutes per session _______
Communication: _______________________________________________________________________
Cognitive Linguistic: ___________________________________________________________________
Swallowing: __________________________________________________________________________
Comments: ___________________________________________________________________________
Skilled Nursing Interventions:
IV or PICC Line Meds / Flushes:
NA
QD
BID
TID
Other ________________
Description of IV Therapy: _____________________________________________________
G Tube:
No
Yes
Date Initiated: _________________ % of nutrition: ________________
Wound Care: NA QD BID TID
Describe wound treatment: ______________________________
Other Skilled Intervention: _______________________________________________________________
Anticipated Date of Completion of Therapy / Treatment Plan: ___________________________

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