Form Pro-116-D - Bcbs Request For Certification Form
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1
2Health Management Division
REQUEST FOR CERTIFICATION*
An Independent Licensee of the Blue Cross and Blue Shield Association
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
ICD10
____________________________________________________________________________
Secondary Diagnosis
_______________________________________________________________________________
Start of Hospice
PLACE OF CARE
_____
_____
_____
:
Home Care
Inpatient Hospice
Respite
Inpatient
Home
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
Dementia/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
*Failure to Thrive and Generalized Weakness are not eligible diagnosis for benefit coverage*
History and Progression of Disease
(attach clinical notes)
(Worsening symptoms, change in mental status, declining physical function, weight loss, etc.)
Vital signs:
_____ B/P
_____ P
_____ R
_____ T
_____ Ht
_____ Wt
_____ BMI
Karnofsky score ___________
O2 sats Room Air__________
O2 sats max O2 ___________
Brief Description: ___________________________________________________________________________________
PMH : ____________________________________________________________________________________________
Progression of Disease:________________________________________________________________________________
___________________________________________________________________________________________________
Recent laboratory data and dates: BUN/Cr __________
Albumin _________
Hct/Hgb _________
PRO-116-D (Rev. 11-2015) Front
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