If PM admission is planned, please provide justification:
Total # of pages faxed, including cover page
EXPEDITE !! The provider believes that waiting for a decision under the standard time frame could place the enrollee's life, health, or ability to regain maximum function in serious jeopardy (CMS definition)
This form must be filled out completely. Chart notes are required and need to be submitted with this request. Incomplete requests will be returned to the requestor.