BadgerCare Plus & Medicaid SSI Provider Manual - Group Health ...
BadgerCare Plus & Medicaid SSI Provider Manual - Group Health ...
BadgerCare Plus & Medicaid SSI Provider Manual - Group Health ...
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Inpatient Treatment<br />
Services Request Form<br />
Member Name: ____________________ Member ID:_____________ DOB: _____________<br />
*Attach H&P and clinical information including medications and fax to: (715) 852-5755<br />
<br />
<br />
Axis I: ___________________<br />
Axis II: ___________________<br />
Axis III:___________________<br />
Axis IV:___________________<br />
Chapter 51/Emergency Detention<br />
Mental <strong>Health</strong><br />
Detox<br />
Inpatient AODA<br />
Axis V: ____________________<br />
Date of Admission __/__/__ Estimated Length of Stay: _____ Actual D/C Date: __/__/__<br />
Brief Summary of Current Clinical Status/Admission Information:<br />
____________________________________________________________________________<br />
____________________________________________________________________________<br />
____________________________________________________________________________<br />
____________________________________________________________________________<br />
<strong>Provider</strong> Name:_______________________ Phone: _________________ Fax: ____________<br />
Facility Name: ________________________Address: _________________________________<br />
Tax ID: __________________________<br />
I certify that I am the provider who will be delivering the services listed above and that the information<br />
contained herein is true and correct to the best of my knowledge.<br />
<strong>Provider</strong> Signature _________________________________________ Date_______________<br />
The submission of supporting clinical documentation/plan of care is required with this form<br />
Fax completed form to: (715) 852-5755 <strong>Group</strong> <strong>Health</strong> Cooperative <strong>Health</strong> Management Phone: (800) 218-1745<br />
Revised: 3/24/11 <strong>Health</strong> Management Fax: (715) 852-5755<br />
GHC11022