Inpatient Rehab/SNF and Emergent Admissions Form
Instructions: Complete form and fax to the number above. We follow InterQual criteria for review.
HIPAA regulations prohibit sending more clinical information than is needed for pre-cert. Do not submit the entire medical record. Only submit the information required on this form or the requested attachments. Please include H&P, pertinent consults, and last MD progress note available with all requests.
Specified skilled service information:
For all supporting specified skilled service information, please attach any related files, note specific to the request above, list the name of the patient and their HAP ID in the body of the email, and send them to IPRS@hap.org.