Web Forms or Files Description
PCF01 (PDF Format) Required for ALL Precert submissions. It should be submitted with the Precertification Case Number in the upper right hand corner for all extensions, resubmittals, reconsiderations, and updates.  
PCF02 (PDF Format) An abstract or summary form used to request acute care extensions, physicians reconsideration reviews, or to support medical necessity for inpatient admission for out-patient procedures. Revised 7/3/12
PCF03 (PDF Format) An abstract or summary form used to request rehabilitation extensions. This is an optional form. Facilities may choose to summarize the criteria being met with their own summary format.
PCF04 (PDF Format) An abstract or summary form required to request Neonatal Intensive Care Unit (NICU) extensions. Revised 11/11/09
PCF05 (PDF Format) An abstract or summary form used to requests psychiatric or substance abuse extensions. This is an optional form. Facilities may choose to summarize the criteria being met with their own summary format. 
PCF06 (PDF Format) An abstract or summary form used to request long term acute care extensions. This is an optional form. Facilities may choose to summarize the criteria being met with their own summary format.
PCF0A (PDF Format) An abstract form used to document day by day clinical information. This form is to be used for all retrospective reviews.
Rehabilitation Hospital Length Of Stay Criteria (PDF Format) This form is used for each requested length of stay for an inpatient in a rehabilitation hospital.  
Acute Long Term Hospital Length Of Stay Criteria (PDF Format) This form is used for each requested length of stay for an inpatient in a long term acute care hospital.  
Hospital-Based Alcoholism and Drug Treatment Units (PDF Format) This form is used for each requested length of stay for an inpatient on an alcohol or drug treatment unit.  
Psychiatric Unit Admission/Extension Criteria For Adults (PDF Format) This form is used for each requested length of stay for an inpatient on an adult psychiatric unit.  
Psychiatric Unit Admission/Extension Criteria For Children (PDF Format) This form is used for each requested length of stay, for a recipient under the age of 21, on an inpatient psychiatric unit.  
Hospital Admission Form  (PDF Format)
last modified 3/21/02) 		 Inpatient Psychiatric Hospital Admission Form