Tricare For Life Authorization Request Form Skilled Nursing Facility
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1TRICARE For Life Authorization Request
Skilled Nursing Facility
Please return the completed form to:
or
Submit online at
Wisconsin Physicians Service
c/o Medical Review Department
Log into the secured messaging section of
P.O. Box 7934
, to submit your authorization
Madison WI, 53707
request.
Fax: (608) 301-3226
Requesting Provider information
Provider telephone number
(
)
Ext:
*
Provider/Facility address: *
Provider fax number
(
)
*
Contact name
*
Servicing provider/facility name
*
Billing Tax ID #
*
Email address
*
* required fields
Patient Information (please complete all fields)
Sponsor SSN_______________________*
Patient date of birth (mm/dd/yyyy)_______________*
Patient name (Last, First, MI)_______________________________________________ *
Patient address:
* required fields
Requested Service Information
****Authorizations need to be obtained prior to the start of service****
Start date (mm/dd/yyyy):*____________________
Estimated length of stay in days:*__________________
3 day qualifying stay dates (mm/dd/yyyy):* ___________________
Medicare exhaust date (mm/dd/yyyy):* ______________________
Diagnosis Code:*_______________
Description:___________________________________________________
Diagnosis Code: _______________
Description:___________________________________________________
Rug Code: _______________
The following information must be included to help eliminate delays in processing your request:
H&P (History and Physical/Admission)
Nurses Notes
Discharge Summary from acute care stay
Wound care
MD orders
PT notes
(Physical Therapy)
MDS
OT notes (Occupational Therapy)
MD Progress notes
ST notes
(Speech Therapy
* required fields
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