Application For Long Term Care Services Page 2

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SECTION II - Temporary Admission Authorization - To be completed by PAS agency designee or discharge planner designee.

I authorize temporary admission to the nursing facility named on this application for a period of time from the date of admission to the nursing facility, as

designated below. NOTE - This authorization does not apply to PASRR Level II cases; see PASRR forms (State Form 45932 and 45277).

Type of admission:

Direct from hospital

Emergency/APS

30 Day Short Term

Continuing care retirement community

PASRR

(M.D. ETR + 25 up to 120)

(25 days)

(30 days)

(30 days - extend 25 up to 55)

(State Form 45932 or

(Check box)

Level I required)

Hospital Discharge Planner Designee:

Medicaid MCO Enrollee and NF placement for:

Short-Term

Long-Term

(Check all that apply.)

I certify that this patient is a nonresident admitted to acute hospital care after treatment in the emergency room.

I certify that the applicant has been given a list of long term care options that may be available to the applicant,

located within the hospital's service area, and are known to the hospital. (IC 10-12-10-28.5)

Period of care authorized:

Start date (month, day, year)

Stop date (month, day, year)

Signature of (check one)

IPAS agency or

Discharge Planner Designee (for direct from in state acute care only)

Date (month, day, year)

Affiliation

Telephone number

FAX number

(

)

(

)

Name of nursing facility / address (number and street, city, state, and ZIP code)

This document contains protected health information which is covered by the Health Insurance Portability and

Accountability Act (HIPAA) and may only be disseminated to authorized individuals.

SECTION III - Estimated Nursing Facility Cost - To be completed by the nursing facility.

Name of nursing facility / address (number and street, city, state, and ZIP code)

Name of applicant

Per 460 IAC 1-1-8(e), the nursing facility must provide to the IPAS agency an estimate of the cost of all services that the applicant is anticipated to require.

State level of NF services needed

Estimated NF cost for NF services at the rate charged to private payers

Information provided by

Telephone number

FAX number

(

)

(

)

DISTRIBUTION:

Original - IPAS Agency

Applicant