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 Sub-Acute Rehabilitation (SAR) under Priority Health products. It outlines the necessary information required for admission, continued stay, and discharge requests, including patient details, admitting diagnosis, 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 selecting the type of request: Admission, Continued Stay, or Discharge. This is crucial for processing your request accurately.
Fill in the Member Information section with details such as Name, Priority Health ID#, and Date of Birth. Ensure all fields are completed to avoid delays.
Indicate the Transfer from Hospital or Facility Name and check the appropriate boxes for admitting status (e.g., ED, Home).
Complete the Admit to section by providing the admit date, facility name, address, and contact information. This ensures proper communication with the facility.
In the CURRENT DISCHARGE PLAN section, estimate length of stay and anticipated discharge disposition. Include caregiver details and services ordered upon discharge.
Finally, review all entries for accuracy before submitting your form through our platform for timely processing.

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

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