To submit this form, ensure all required fields are completed and all necessary supporting documents are attached. Fax the completed form and documents to (909) 912-1045. For more information or assistance, contact the provider's office.

No specific important dates provided for this form in the content.

The purpose of this form is to request skilled nursing facility services for members of Inland Empire Health Plan. It ensures that the necessary information for service requests is documented accurately and thoroughly. Proper completion facilitates timely processing and approval of service requests, ensuring members receive the required care.

• 1. Request Urgency: Indicates the urgency of the request, such as standard or expedited.
• 2. Request Date: The date on which the request is made.
• 3. Requested By: The name of the person making the request.
• 4. Requesting Provider: The name and contact information of the provider requesting the service.
• 5. Member Name: The name of the member for whom the service is requested.
• 6. DOB: Date of birth of the member.
• 7. IEHP Member ID: Member ID number for Inland Empire Health Plan.
• 8. Expected Discharge: Expected discharge date for the member.
• 9. Requested Service: Description of the service being requested.
• 10. CPT/Procedure Code(s): CPT or procedure codes related to the requested service.
• 11. ICD/Diagnosis Code(s): Diagnosis codes related to the requested service.
• 12. Provider Name: The name of the servicing provider.
• 13. NPI: National Provider Identifier.
• 14. Provider Address: Address of the servicing provider.
• 15. Phone: Contact phone number for the servicing provider.
• 16. Fax: Fax number for the servicing provider.
• 17. Contact Person: Name of the contact person for the provider.
• 18. Confirmed: Indicator if the service has been confirmed.
• 19. Form Requirements: Instructions and requirements for completing and submitting the form.

Failing to submit this form could result in delays or denial of the requested services. It is crucial to complete all required fields and provide supporting documentation for timely processing.

• Delays in Processing: The service request may be delayed if the form is incomplete.
• Denial of Service: The request may be denied if essential information is missing.
• Member Inconvenience: Incomplete submissions may inconvenience the member requiring care.

• 1. Discharge Planning: Use this form to request services for patients being discharged from a healthcare facility.
• 2. Initiating Services: Complete this form when initiating new skilled nursing services for a member.
• 3. Updating Service Requests: Use this form to update or modify existing service requests.
• 4. Insurance Verification: Submit this form to verify and request approval for services with insurance providers.
• 5. Case Management: Case managers use this form to document and request necessary skilled nursing services for their patients.