44FAX to Mercy Care Inpatient Notification 8558253165 Date Completed TIMEType of Service Requested Psychiatric Acute Hospital Subacute Facility IMD Client Information Name Date of Birth Address AHCC ID: 886247
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1 4 4 A CON must be completed at the time
4 4 A CON must be completed at the time of admission or date and time admission FAX to Mercy Care Inpatient Notification: 855-825-3165 Date Completed: TIME ) ( Type of Service Requested: Psychiatric Acute Hospital Sub acute Facility IMD Client Information Name: Date of Birth: Address: AHCCC S ID: Provider: Provider Phone #: Facility: Diagnosis (Must be numeric value per ICD 10 criteria): Please indicate why proper treatment of the person’s behavioral health condition requires services on an inpatientbasis under the direction of a physician. I am aware of the client’s condition and have been provided sufficient information to determine this level of care is appropriate. __________________________________ Print Name __________________________________ Date: Proposed Placement: Level I Provider Name: Facility: Requested Service Dates: From: To: Discharge: Completed By (Name): Contact Info (phone): Proprietary