21355c 2025

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The document is a Prior Authorization/Review Form for patients admitted to Acute Rehabilitation, Long-Term Acute Care (LTAC), Skilled Nursing Facilities (SNF), or Subacute Rehabilitation (SAR) under Priority Health products. It outlines the necessary information required for admission, continued stay, and discharge requests, including patient details, facility information, nursing needs, and discharge plans. The form emphasizes the importance of completing all fields for timely processing and includes instructions for submitting the form and related documents.

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Click ‘Get Form’ to open the 21355c in the editor.
Begin by filling out the 'Member Information' section. Enter the member's name, Priority Health ID number, and date of birth. Ensure all fields are completed for accurate processing.
Select the type of request: Admission, Continued Stay, or Discharge. Check the appropriate boxes based on the patient's situation.
In the 'Admit to' section, specify the facility name and address. Include contact details and admit date for seamless communication.
Complete the 'CURRENT DISCHARGE PLAN' section by estimating length of stay and anticipated discharge disposition. This information is crucial for planning patient care.
Fill out nursing needs and current physical function sections accurately to provide a comprehensive overview of patient requirements.
Review all entries for completeness before submitting. Use our platform’s features to save your progress or make edits as needed.

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Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (200 Votes)

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