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Swing Bed
Primewest Health Medicare Swing Bed Notification Form
Hospital name
-- Select one --
{{option.name}}
Please specify "other"
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Hospital admission date
Invalid date
Date is required
Date cannot be before {{appCtrl.minDate| date:'M/d/yyyy'}}
Date cannot be after today
Health care provider/physician name
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Member PMI#
Only digits are allowed
Member first name
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Member last name
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Member date of birth
Is the Swing Bed facility attached to the hospital to which the member was originally admitted?
Yes
No
Please make a selection.
Swing bed admission date
Invalid date
Date is required
Date cannot be before {{ appCtrl.minDate | date:'M/d/yyyy'}}
Date cannot be after today
Swing bed admission diagnosis
-- Select one --
{{option.name}}
Please specify "other"
Invalid character
Attempted to find Skilled Nursing Facility (SNF) bed within 25 miles?
Yes
No
Please make a selection.
Facilities contacted (if none were contacted, please explain)
Skilled service
Select skilled service
IVs
IMs
TF
Other (describe)
Must have at least one skilled service
Specify skilled service
Physical therapy (describe)
Occupational therapy (describe)
Speech language pathology (describe)
Teaching training (describe)
Observation and assessment (describe)
Skilled management (describe)
Can SNF provide skilled service?
Yes
No
Please make a selection.
Can services be provided in the home?
Yes
No
Please make a selection.
Hospice?
Yes
No
Please make a selection.
Comments
Family requested swing bed?
Yes
No
Please make a selection.
Completed by first name
Invalid character
Completed by last name
Invalid character
Phone
Please fill out all required selections.
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PrimeWest Health is NCQA accredited for our Families and Children and MinnesotaCare programs.
