Acute PA Form 2026

1. Click ‘Get Form’ to open the Acute PA Form in the editor.
2. Begin by selecting whether this is a new admission or a continued stay. If it’s a continued stay, enter the case reference number and proceed to the Member Information section.
3. For new admissions, indicate the request type by checking the appropriate box for urgent or scheduled admission. Ensure you understand that urgent admissions require faxing within three business days.
4. Fill out the Member Information section completely, including the patient's name, date of birth, Medicaid ID number, and primary diagnosis description.
5. Next, provide details about the admitting facility. Include the facility name, today's date, NPI number, UR phone and fax numbers, and contact information for the person submitting the request.
6. Review all entered information for accuracy before submitting. Ensure that any required supporting documentation is attached.

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