Inpatient Request to Admit from Home

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* Required

Enter Patient Information

• Facility: *
  Select Facility Childrens Mercy Hospital Shawnee Mission Medical Center Liberty Hospital Mosaic Life Care Olathe Medical Center Out of Area Clinical Reviews (Outside of the Kansas City Metro Area) Other Kansas City Metro Hospitals Providence Hospital St. Marys Hospital/St. Joseph Hospital Truman-Bothwell-Western Missouri Med Ctr
• Blue KC ID (Not SS#): *
  • i
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• Patient First Name: *
• Patient Middle Initial:
• Patient Last Name: *

• Date of Birth: *
• Group ID: *
• Date of Service/Admission Date: *
• ICD-10 Diagnosis Codes: *

  Diagnosis Codes must be 3-8 characters along with decimals

  Codes must be 3 - 8 characters along with decimals.
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* Required

Enter Provider Information

• Provider ID OR NPI: *
• • I am an Admitting Physician
  • I am an Attending Physician
• Admitting Physician's Name:
• Admitting Physician's Address:
• Admitting Physician's City:
• Admitting Physician's State:
• Admitting Physician's Zip:
• Admitting Physician's Email Address:
• Admitting Physician's Phone No:
• Admitting Physician's Fax No:*
• Attending Physician's Name:
• Servicing Attending's Address:

• Attending Physician's City:
• Attending Physician's State:
• Attending Physician's Zip:
• Attending Physician's Email Address:
• Attending Physician's Phone No:
• Attending Physician's Fax No:*
• Contact First Name: *
• Contact Last Name: *
• Contact Email Address:
• Contact Phone No:
• Contact Phone Ext:
• Contact Fax No:*

You are required to include and attach all of the following:

Choose a file or files to attach (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif) *

To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.

Choose a file or files to attach (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif) *

To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.

Choose a file or files to attach (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif)

To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.

• Name of Facility accepting the transfer: *
• Contact Name: *
• Contact Address: *
• Contact Phone Number: *
  Enter a 10 digit phone number.
• Contact Fax Number: *
  Enter a 10 digit fax number.

• Checking this box will send a copy of your form to the email address provided.