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16345 Henderson Rd, Milton, GA 30004MLS# 6527065

16345 Henderson Rd, Milton, GA 30004MLS# 6527065 2026

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4.3 out of 5

30 votes

The document is an Inpatient Admission Form that outlines the procedures for notifying health plans about patient admissions, including specific fax numbers and timelines for Apple Health/Medicaid and Medicare Advantage Plans. It includes sections for facility information, patient details, admission information, and newborn information for OB admissions. The form emphasizes that notification does not guarantee payment and provides contact numbers for verifying eligibility and benefits.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the Facility Information section. Enter the Hospital Name, Contact Name, Today’s Date, Phone Number, Fax Number, and Tax ID.
Next, move to the Patient Information section. Input the First Name, CHPW Member ID, Last Name, Middle Initial (MI), and Date of Birth. If applicable, include the Retro Enrolled Date.
In the Admission Information section, specify the Admit Date and Time. Choose the Admit Type from Routine, Urgent (Direct Admit or Transfer), or Emergent (Through ED). Also provide the Admitting Physician's name and Admitting Diagnosis.
If applicable for OB admissions, complete the Newborn Information section with Sex, Date of Birth, First Name, Delivery Type (Vaginal or C-Section), Bed Type (Regular Nursery or Special Care Nursery/NICU), and Attending Pediatrician details.

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Versions	Form popularity	Fillable & printable
2022	4.8 Satisfied (45 Votes)
2019	4.3 Satisfied (30 Votes)

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