Inpatient form 2025

1. Click ‘Get Form’ to open the inpatient authorization form in the editor.
2. Begin by filling out the facility information. Enter the facility name and provider tax ID, followed by the service address.
3. Next, provide member information. Fill in the last name, first name, Priority Health ID number, and date of birth.
4. Indicate the type of request by selecting one of the options: Pre-service, Concurrent, or Retrospective.
5. Select the level of care required from options such as MH inpatient or Inpatient detox. Specify any specific dates of service requested.
6. Complete details for discharge including discharge date and Axis assessments (I through V). List any discharge medications prescribed.
7. Outline follow-up care needs by providing therapy and psychiatry appointments along with a current phone number for member follow-up.
8. Finally, fill in contact information for the reviewer requesting authorization and add any additional comments if necessary.

Start using our platform today to easily complete your inpatient form online for free!