SNF/Acute Rehab/LTAC – Initial Request ONLY Member InformationEnter Member Id and Date of Birth and click Submit below to validate the member and fetch Member Details.Member ID* Member DOB* MM slash DD slash YYYY Member Name* First Last Error Field Provider InformationRequesting Facility/Provider Name* Contact Name* First Last Contact Phone #*Contact Fax #*Email Address* In order to receive confirmation of receipt request Name of Ordering Physician* First Last Date of Admission to SNF/Acute Rehab/LTAC (If Known) MM slash DD slash YYYY Level of Care*Level of Care *SNF SkilledSNF CustodialAcute RehabLTACAccepting Facility (If Known and Different From Requesting Facility) Accepting Facility NPI (If Known) Clinical InformationDiagnosis (Click + or - at the right to add additional Diagnoses)*DiagnosisICD 10 Diagnosis Code Example ICD 10 Diag Code: Z87.890Purpose of Referral* Rehab Therapy (PT, OT, ST) Skilled Nursing (IV, meds/Complex wound care, etc) Respiratory -Vent, Trach Custodial, non-skilled services Please include any important documents of medical necessity for the requested level of care such as rehab evaluation, skilled or non-skilled needs, progress notes, discharge planning notes. Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 23 MB. Additional Comments Agreement* Authorization is not a guarantee of paymentCAPTCHA