Utilization Management Forms

Prior Authorization

• Gastric bypass authorization
• Vagal nerve stimulation authorization

Pre-admission Certification

• Psychiatric review admission certification
• Chemical dependency admission certification
• Physical rehabilitation admission certification
• Skilled nursing extraordinary care admission certification
• Transplant pre-admission certification

Continued Stay

• Psychiatric continued stay
• Chemical dependency continued stay
• Physical rehabilitation continued stay
• Skilled nursing extraordinary care continued stay

Retrospective Review

• Retrospective review form

Discharge

• Psychiatric or chemical dependency discharge

Department of Family Services (DFS) Forms

Preadmission Certification Forms

• Psychiatric authorization
• Chemical dependency authorization

Continued Stay Forms

• Psychiatric continued stay
• Chemical dependency continued stay

Discharge Forms

• Psychiatric or Chemical dependency discharge

Policies

• Gastric bypass surgery policy
• Physical rehabilitation services policy
• Transplant policy
• Vagus nerve stimulation policy