Adult Day Step 1 of 4 25% Member InformationEnter Member Id and Date of Birth to validate Member before proceeding with the form. Member's ID#* Member's DOB* MM slash DD slash YYYY Start Date* MM slash DD slash YYYY End Date* MM slash DD slash YYYY Member's Name* First Last Error Message Facility InformationAdult Day facility NPI* 10 digitsAdult Day Facility Name* Error Message Phone #*Fax #*Contact Name* Email address in order to receive confirmation of request receipt* Clinical InformationDiagnosis (Click + or - at the right to add up to 5 Diagnoses)*DiagnosisICD 10 Diagnosis Code Example ICD 10 Diag Code: Z87.890HCPC/S Code(s) and 2 digit modifier (Click + or - at the right to add up to 5 HCPC/S Codes)* Example HCPC code: S1234 with modifier: S1234 U1Attendance Schedule: Anticipated number of days attending* Sunday Monday Tuesday Wednesday Thursday Friday Saturday Date of Last Physical Exam* MM slash DD slash YYYY Recipient Goals (Explain recipient’s individualized goals for enhancing his/her functioning and/or maintaining/improving his/her quality of life through services provided at the facility.)* Requested Services*Based on the physician evaluation and assessment, the following services are requested (Check all that apply): Skilled Care: At least one skilled service by a Registered, Professional Nurse (RN) or a Licensed Practical Nurse (LPN). Non Skilled Care At least two (2) Activities of Daily Living (ADL). Non Skilled At least one (1) Activity of Daily Living which requires a two- person Assist to complete ADL. Non Skilled At least 3 Activities of Daily Living when supervision and cueing are needed to complete the ADLs identified An individual who has been diagnosed with Alzheimer’s disease or other related dementia or a mental health diagnosis as determined by a physician and requires regular staff interventions due to safety concerns. Attach Clinical*Accepted file types: pdf, doc, docx, Max. file size: 200 MB.Signature of Physician or Licensed Provider (Required for skilled service)*Signature Date:* Request Method*Request Method *StandardExpedited: By checking Expedited, you are stating that processing this request in the standard time (14 days) for making a determination could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function. Please attach documentation that supports the need for an Expedited decision. Also please note that a request with a date of service in the past cannot be considered as Expedited.Attach additional Clinical documents for Expedited request*Accepted file types: pdf, doc, docx, Max. file size: 23 MB.Upload only PDF or Word DocumentsSignature of Physician or Licensed Provider (Required for Expedited request)*Signature Date:* CommentsAuthorization is not a guarantee of paymentCAPTCHA