Referral Form  Expedited

(Requires Physician Signature)

Please fax this form along with required documentation
To Fax# 305-418-9378 or 1-855-481-0606 x__________________

 Initial Request  Recertification

Policy Number: Patient Last Name: Patient First Name:
0123456789 test test
Health Plan: Date of Birth: Phone Number:
coastal 05/06/1992 770-209-9001
Service address:
312 n wwarrington rd. pensacola, fl 32506
Sender’s Name OR Company Name and Number: Discharge Facility: Discharge Date:
PREMIER KIDS CARE NPI: 1588299317
Diagnosis- ICD-10 Codes S.O.C
Requested start date of service:
E10.9 -TYPE 1 dm w/out complications 11/6/22-5/5/23 *6 month time span*
Services Requested UNLESS CMN WILL NOT BE ACTIVE
 Home Health Orders (If HH is not ordered By MD or DO must be countersignedFOR
by the
Aattending
FULL physician)
6 MONTHS THEN USE
 Nurse Evaluation –for home or wound care needs & treatment ______________________________________________
CMN EXPIRATION DATE

Wound care treatment plan & Location: _____________________________________________________________________

________________________________________________________________________________________________________

 Physical Therapy Evaluation & Treatment O.T Evaluation S.T Evaluation

 Home infusion/ Medication Administration, Medication, dosage, route & frequency/ duration:

______________________________________________________________________________________________

 Other:

 Durable Medical Equipment and Supplies(Power Mobility devices orders must include a Physical Therapist evaluation)
✔
Please describe

A4232 X 10 (PT USES 1 1/2 BOXES PER MONTH)

__________________________________________________________________________________________ Height: _______

A4230 X 10 (PT USES 1 1/2 BOXES PER MONTH)

__________________________________________________________________________________________ Weight:_______
PODS - A9274 X 10 (PT USES 1 1/2 BOXES PER MONTH)
 Oxygen Therapy:  CPAP Therapy: ______Initial


 O2 Saturation Level on Room Air _________%
BIPAP Therapy: ______ Extension of existing rental
 Date O2 Sat was taken: __________________
Date of SOC ________________
 Taken @ rest or with ambulation: _______________
 Settings __________________
 If taken with ambulation- resting O2 Sat: _________%
 Baseline AHI _______________
 Bled into CPAP/BIPAP : Yes ________ No________
For PAP Rental extension please provide PAP Compliance Report.
Script needs to have dx, settings (liters per minute, route of
For Initial PAP Rental please attach baseline sleep study report.
administration, continuous or nocturnal) AND oxygen saturation on
For Bipap therapy, please provide two (2) pressure settings.
room air.
Ordering Physician Information (If no Dr’s signature, must attach signed Rx)
Name of Ordering physician: NPI # Date:

Signature Phone: Fax:

**Attach any clinical notes, H&P, discharge orders, labs, and imaging reports to support medical necessity**
Source: Global\PA_Form_Coastal_Care Original document #: 6056232 received on 2/6/2023 CCSI-01/21
2:20 PM EST