Form Pro-117-D - Bcbs Request For Certification Form
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1
2Federal Employee Program
REQUEST FOR CERTIFICATION*
Hospice Services prior to or within 5 days of start of care
* Benefit Verification: Please verify before submission of information *
NAME OF HOSPICE
*After initial certification 30 day review required unless otherwise specified by case manager*
PATIENT INFORMATION
Patient Name __________________________________________________________________________________________________
Patient Address_________________________________________________________________________________________________
Patient Telephone ________________________________________________ DOB __________________________________________
Name of Contract Holder _________________________________________________________________________________________
Primary Caregiver ________________________________________________ Telephone number _______________________________
Contract Number _________________________________________________
Secondary Insurance ______________________________________________
Primary Hospice Diagnosis _______________________________________________ ICD 10 ___________________________________
Secondary Diagnosis ____________________________________________________________________________________________
Start of Hospice ________________________________________________________________________________________________
SERVICES PROVIDED
(indicate all and how often)
_____
SN
_____MSW
_____HHA
_____Chaplain
_____Therapist
_____MD/CRNP
_____
DME:
Hospital bed
Bedside Commode
Oxygen/supplies
BiPap
Wheelchair Walker/cane
Nutritional supplements
______________________________________________________
IV fluids
Wound care
Other
CLINICAL
Disease Specific Clinical Information
Heart Disease
Pulmonary Disease
Alzheimer Disease/Progressive Neurologic
HIV
__
__
__
__
NYHA class 4
Dyspnea at rest
Unable to walk
CD4 count < 25
__
__
__
__
TX: diuretics/vasodilators
Right heart failure
Dependent in ADLs
Viral load > 100,000
__
__
__
__
Cardiac arrest/syncope/cva
O2 sat: max O2 support
Speech < 6 intelligible words
Karnofsky < 40
__
__
__
__
Documented ED visits/adm
PCO2 > 55
Unintentional weight loss
Comorbidities
__
__
__
No Transplant option
Unintentional weight loss
Comorbid conditions
Liver Disease
Renal Disease
ALS
__
__
__
INR > 1.5
No Dialysis
Karnofsky < 40
__
__
__
Albumin < 2.0
Cr clearance <10 ml/min
Impaired pulmonary status
__
__
__
Refractory ascites
Serum Cr > 6.0
Dysphagia/unable to support life
__
__
Recurrent variceal bleed
Comorbidities
__
Jaundice
__
Malnutrition/muscle wasting
Diagnosis not eligible for benefit coverage
Failure to thrive, dementia, generalized weakness*
*
:
HISTORY AND PROGRESSION OF DISEASE
(attach clinical notes)
(Worsening symptoms, change in mental status, declining physical function, weight loss, dementia, etc.)
Vital signs:
_____ B/P
_____ P
_____ R
_____ T
_____ Ht
_____ Wt
_____ BMI
Karnofsky score ___________
O2 sats on Room Air__________
O2 sats @ max O2 ___________
Brief Description: ___________________________________________________________________________________
PMH :_____________________________________________________________________________________________
Progression of Disease: ______________________________________________________________________________ __
_____________________________________________________________________________________________ _ ____
Recent laboratory data and dates: BUN/Cr __________
Albumin _________
Hct/Hgb _________
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PRO-117-D (Rev. 11-2015) front
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