Skilled Nursing Facility & Acute Rehabilitation Facility 2026

The document is a Skilled Nursing Facility & Acute Rehabilitation Facility Fax Assessment Form designed to collect clinical information necessary for evaluating admissions or continued stays in such facilities. It outlines the required fields, disclaimer statements, and attestation by facility representatives. The form includes sections for member and facility information, admission details, clinical data, medication changes, mobility status, therapy goals, discharge plans, and authorized signatures.

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Click ‘Get Form’ to open it in the editor.
Begin with Section I, where you will select the type of facility (SNF or Acute Rehabilitation) and indicate the number of days requested.
In Section II, provide member and facility information. Fill in the member's name, date of birth, address, and policy number. Ensure all fields are legible.
Proceed to Section III for admission details. Enter the admission date, admitting doctor’s information, diagnosis reason, and any complications or surgical procedures.
In Section IV, complete clinical information including vital signs and mobility status. Be thorough with medication changes and skin status.
Finally, in Section V, sign off with your name and credentials before submitting the form as instructed in Section VI.

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