Blue ltch print 2025

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4.8 out of 5

30 votes

The document is an Initial Precertification Form for skilled nursing, long-term care hospital, or rehabilitation hospital services. It provides instructions for completing and submitting the form to request authorization for these services, along with sections for member and facility information, admission details, clinical status, treatment plans, and discharge goals. Specific guidelines are included for ambulance services and recertification requests.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (30 Votes)
2012	4.2 Satisfied (42 Votes)

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