Inpatient Transfer Request Review Form

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* Required

Enter Patient Information

Facility: *
Blue KC ID (Not SS#): *
- i
- i
- i
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.

* 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:*

Indicate the level of care: *

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

Diagnosis (explain) * Plan to accomplish at the lower level of care (explain) *

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.

Most recent Physical Therapy, Occupation Therapy, and Speech Therapy notes *

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.

Prior level of functioning - include home environment and support system (explain) *

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 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.

If you experience issues submitting this form, please print and fax it to (816) 995-1580.

Cancel

Your prefix is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

IMPORTANT: If you are an FEP Member, enter "NA" into the Prefix field.

Your member ID is a unique number that identifies your plan. It is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

Your Suffix is a two digit number located on your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

For Blue Card members, suffix is not required.

Inpatient Transfer Request Review Form

Enter Patient Information

Enter Provider Information

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